Provider Demographics
NPI:1184235541
Name:UNDERWOOD, TAYLOR J
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:J
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 S HIGHLAND AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5329
Mailing Address - Country:US
Mailing Address - Phone:815-993-8831
Mailing Address - Fax:
Practice Address - Street 1:701 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1520
Practice Address - Country:US
Practice Address - Phone:708-354-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490222881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical