Provider Demographics
NPI:1013083641
Name:TAYLOR, THERESA E (BACB)
Entity Type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:E
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:BACB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CHARNOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-1111
Mailing Address - Country:US
Mailing Address - Phone:508-887-1652
Mailing Address - Fax:
Practice Address - Street 1:191 BARRE PAXTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:MA
Practice Address - Zip Code:01543-1239
Practice Address - Country:US
Practice Address - Phone:508-321-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1062795101Y00000X
MA848103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor