Provider Demographics
NPI:1790467074
Name:ROSS, TAYLOR BLAKE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BLAKE
Last Name:ROSS
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 1:304 WASHINGTON BLVD APT 1S
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4161
Mailing Address - Country:US
Mailing Address - Phone:309-269-4924
Mailing Address - Fax:
Practice Address - Street 1:212 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5232
Practice Address - Country:US
Practice Address - Phone:630-664-1449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178017244101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health