Provider Demographics
NPI:1184938524
Name:TAYLOR, NICOLE (PHD, JD)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PHD, JD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WAGSTAFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:530 E HUNT HWY
Mailing Address - Street 2:STE. 103-250
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-6581
Mailing Address - Country:US
Mailing Address - Phone:480-510-5549
Mailing Address - Fax:
Practice Address - Street 1:321 N. BAILEY STREET
Practice Address - Street 2:#D
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132
Practice Address - Country:US
Practice Address - Phone:480-510-5549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3821103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical