Provider Demographics
NPI:1730116419
Name:TAYLOR, REBECCA L (AUD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:S
Other - Last Name:WAITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:210 W GEORGIA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5688
Practice Address - Country:US
Practice Address - Phone:208-468-5915
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD1089231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1730116419Medicaid