Provider Demographics
NPI:1891933776
Name:TAYLOR, DIANE JANE (MSCCCSL)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:JANE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MSCCCSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 INNSBRUCK CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-4944
Mailing Address - Country:US
Mailing Address - Phone:920-468-3230
Mailing Address - Fax:
Practice Address - Street 1:600 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3503
Practice Address - Country:US
Practice Address - Phone:920-432-3213
Practice Address - Fax:920-432-0614
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI339-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42618800Medicaid