Provider Demographics
NPI:1689918872
Name:TAYLOR, GAVIN HENDERSON (DCLINPSY)
Entity Type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:HENDERSON
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DCLINPSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CENTURY HILL DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 CENTURY HILL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2116
Practice Address - Country:US
Practice Address - Phone:518-785-7283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019877-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1215152962OtherPRACTICE NPI