Provider Demographics
NPI:1093191157
Name:EDGCOMB, TAYLOR (MA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:EDGCOMB
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S IVY ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4339
Mailing Address - Country:US
Mailing Address - Phone:714-834-1111
Mailing Address - Fax:
Practice Address - Street 1:312 S JUNIPER ST STE 202
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4998
Practice Address - Country:US
Practice Address - Phone:888-428-3223
Practice Address - Fax:323-866-1881
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140121627101YS0200X
106E00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst