Provider Demographics
NPI:1649694704
Name:TAYLOR, CHARLENE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:TAYLOR
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 1:4149 N HOLLAND SYLVANIA RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SYLVANIA TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4808
Mailing Address - Country:US
Mailing Address - Phone:419-206-5367
Mailing Address - Fax:
Practice Address - Street 1:4149 N HOLLAND SYLVANIA RD
Practice Address - Street 2:SUITE 8
Practice Address - City:SYLVANIA TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:43623-4808
Practice Address - Country:US
Practice Address - Phone:419-206-5367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0500342101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional