Provider Demographics
NPI:1639457559
Name:RAE, TAYLOR (P-LCSW)
Entity type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:
Last Name:RAE
Suffix:
Gender:F
Credentials:P-LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 FITZSIMMONS DR
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-2303
Mailing Address - Fax:253-968-1151
Practice Address - Street 1:PO BOX 1192
Practice Address - Street 2:
Practice Address - City:DONNELLY
Practice Address - State:ID
Practice Address - Zip Code:83615-1100
Practice Address - Country:US
Practice Address - Phone:253-968-2303
Practice Address - Fax:253-968-1151
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2025-02-04
Deactivation Date:2024-09-23
Deactivation Code:
Reactivation Date:2024-11-26
Provider Licenses
StateLicense IDTaxonomies
NCP-006670390200000X
IDLCSW365371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program