Provider Demographics
NPI:1265089924
Name:PAVLAK, TAYLOR (DPT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:PAVLAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-2784
Mailing Address - Country:US
Mailing Address - Phone:618-550-9107
Mailing Address - Fax:
Practice Address - Street 1:1000 ELEVEN S STE 1B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1078
Practice Address - Country:US
Practice Address - Phone:618-550-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist