Provider Demographics
NPI:1629602974
Name:NIXON, TAYLOR MARIE (BS)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:NIXON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34166 GUN CLUB RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62012-3617
Mailing Address - Country:US
Mailing Address - Phone:618-560-9139
Mailing Address - Fax:
Practice Address - Street 1:601 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-92592106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty