Provider Demographics
NPI:1902205867
Name:PATRICK, TAYLOR (MT)
Entity Type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:
Last Name:PATRICK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4049 MAXANNE DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2177
Mailing Address - Country:US
Mailing Address - Phone:678-885-7417
Mailing Address - Fax:
Practice Address - Street 1:4049 MAXANNE DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2177
Practice Address - Country:US
Practice Address - Phone:678-885-7417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-17
Last Update Date:2014-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007910225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist