Provider Demographics
NPI:1811407513
Name:TAYLOR, TARA (LPC-IT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:KOHLER
Mailing Address - State:WI
Mailing Address - Zip Code:53044-1618
Mailing Address - Country:US
Mailing Address - Phone:920-917-5637
Mailing Address - Fax:
Practice Address - Street 1:3424 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1862
Practice Address - Country:US
Practice Address - Phone:920-287-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-07
Last Update Date:2017-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional