Provider Demographics
NPI:1750686721
Name:THOMAS, TAYLOR LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:LEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:LEE
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1815 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1815 PLEASANT GROVE RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7870
Practice Address - Country:US
Practice Address - Phone:870-933-6886
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6895-M104100000X
AR6895-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR194112795Medicaid