Provider Demographics
NPI:1942821483
Name:DEPOL, TAYLOR (RBT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:DEPOL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-0003
Mailing Address - Country:US
Mailing Address - Phone:813-763-5469
Mailing Address - Fax:
Practice Address - Street 1:9111 WHITE BLUFF RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4606
Practice Address - Country:US
Practice Address - Phone:678-381-3677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-117250106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty