Provider Demographics
NPI:1396985792
Name:MASTIN, TAYLOR MARIE (PHD)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:MASTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST.
Mailing Address - Street 2:SPACE BASE DELTA 1
Mailing Address - City:PETERSON SFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1541
Mailing Address - Country:US
Mailing Address - Phone:719-556-4009
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST.
Practice Address - Street 2:SPACE BASE DELTA 1
Practice Address - City:PETERSON SFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-556-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15524-130101YA0400X
COPSY.0004473103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)