Provider Demographics
NPI:1639639305
Name:UPCHURCH, TAYLOR MAY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MAY
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 DESTINY DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62712-5871
Mailing Address - Country:US
Mailing Address - Phone:217-622-4986
Mailing Address - Fax:
Practice Address - Street 1:4017 DESTINY DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62712-5871
Practice Address - Country:US
Practice Address - Phone:217-622-4986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013290235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty