Provider Demographics
NPI:1336210913
Name:TAYLOR, LINDA RAE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:RAE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LINDA
Other - Middle Name:RAE
Other - Last Name:STAIR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:113 LINCOLN WAY EAST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2016
Mailing Address - Country:US
Mailing Address - Phone:574-255-4976
Mailing Address - Fax:574-255-1882
Practice Address - Street 1:113 LINCOLN WAY EAST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2016
Practice Address - Country:US
Practice Address - Phone:574-255-4976
Practice Address - Fax:574-255-1882
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004651A1041C0700X
IN34004651104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000341224OtherANTHEM
IN7701931OtherAETNA
IN218820DMedicare PIN