Provider Demographics
NPI:1922664572
Name:SMITH, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 VARSITY BLVD APT 209
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1549
Mailing Address - Country:US
Mailing Address - Phone:630-697-0224
Mailing Address - Fax:
Practice Address - Street 1:25 N RIVER LN STE 2109
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2003
Practice Address - Country:US
Practice Address - Phone:331-222-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-18
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician