Provider Demographics
NPI:1821437039
Name:TAYLOR, PHILIP J JR
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:TAYLOR
Suffix:JR
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 1:289 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5493
Mailing Address - Country:US
Mailing Address - Phone:757-385-0850
Mailing Address - Fax:
Practice Address - Street 1:289 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5493
Practice Address - Country:US
Practice Address - Phone:757-385-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005435101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1861562472Medicaid