Provider Demographics
NPI:1639151012
Name:ROCKWELL, TAYLOR (PHD)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:
Last Name:ROCKWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 W STEPHENSON ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4940
Mailing Address - Country:US
Mailing Address - Phone:815-232-9050
Mailing Address - Fax:815-232-7233
Practice Address - Street 1:773 W LINCOLN BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4976
Practice Address - Country:US
Practice Address - Phone:815-232-9050
Practice Address - Fax:815-232-7233
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004261103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR18914Medicare UPIN
IL988651Medicare ID - Type Unspecified