Provider Demographics
NPI:1710617766
Name:SLATER, TAYLOR (RBT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:SLATER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RICKEY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-2520
Mailing Address - Country:US
Mailing Address - Phone:850-376-5624
Mailing Address - Fax:850-937-7381
Practice Address - Street 1:103 RICKEY AVE STE C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-2520
Practice Address - Country:US
Practice Address - Phone:850-376-5624
Practice Address - Fax:850-937-7381
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-220286106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-22-220286OtherRBT