Provider Demographics
NPI:1972853513
Name:TAYLOR, ALICEN STEGALL
Entity Type:Individual
Prefix:
First Name:ALICEN
Middle Name:STEGALL
Last Name:TAYLOR
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 1:5316 TRAIL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-1931
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:4801 TROUP HWY
Practice Address - Street 2:SUITE 800
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2356
Practice Address - Country:US
Practice Address - Phone:903-939-2800
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108247235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX207164901Medicaid
TX456606Medicare PIN