Provider Demographics
NPI:1710651526
Name:BLACK, TAYLOR BREANNE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BREANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21600 OXNARD ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:629 PHOENIX DR STE 150
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7341
Practice Address - Country:US
Practice Address - Phone:757-837-0761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician