Provider Demographics
NPI:1679362354
Name:GRESHAM, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 N 104TH PLZ APT 16
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-1146
Mailing Address - Country:US
Mailing Address - Phone:531-247-0869
Mailing Address - Fax:
Practice Address - Street 1:1402 N 104TH PLZ APT 16
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1146
Practice Address - Country:US
Practice Address - Phone:531-247-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities