Provider Demographics
NPI:1245714765
Name:GREEN, TAYLOR LAUREN
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LAUREN
Last Name:GREEN
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 1:618 MOUNT ELBERT WAY
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-1022
Mailing Address - Country:US
Mailing Address - Phone:330-980-3912
Mailing Address - Fax:
Practice Address - Street 1:6396 MCLEOD DR STE 9
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4429
Practice Address - Country:US
Practice Address - Phone:702-287-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker