Provider Demographics
NPI:1356809503
Name:BOTHE-YATES, TAYLOR FAYE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:FAYE
Last Name:BOTHE-YATES
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 1:1050 FULTON AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-4299
Mailing Address - Country:US
Mailing Address - Phone:916-974-2599
Mailing Address - Fax:
Practice Address - Street 1:1013 SYRACUSE CIR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4671
Practice Address - Country:US
Practice Address - Phone:575-749-8947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-47223103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician