Provider Demographics
NPI:1669079802
Name:DIEBALL, TAYLOR ALEXIUS (RBT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ALEXIUS
Last Name:DIEBALL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:ALEXIUS
Other - Last Name:BEAUCHAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:4655 ROSEBUD LN
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-9366
Practice Address - Country:US
Practice Address - Phone:812-213-8031
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-133373106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician