Provider Demographics
NPI:1780189985
Name:TAYLOR, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17924 W LAS PALMARITAS DR
Mailing Address - Street 2:
Mailing Address - City:WADDELL
Mailing Address - State:AZ
Mailing Address - Zip Code:85355-7812
Mailing Address - Country:US
Mailing Address - Phone:478-321-7070
Mailing Address - Fax:
Practice Address - Street 1:650 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1839
Practice Address - Country:US
Practice Address - Phone:478-321-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC16308101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor