Provider Demographics
NPI:1821286279
Name:TAYLOR, RANDIE JILL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RANDIE
Middle Name:JILL
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2124
Mailing Address - Country:US
Mailing Address - Phone:631-471-0688
Mailing Address - Fax:
Practice Address - Street 1:2780 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 209
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2124
Practice Address - Country:US
Practice Address - Phone:631-471-0688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP57441103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist