Provider Demographics
NPI:1740897719
Name:FREDERICK, TAYLOR BOULET
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:BOULET
Last Name:FREDERICK
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 1:123 WESTMARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-7345
Mailing Address - Country:US
Mailing Address - Phone:337-255-0950
Mailing Address - Fax:337-466-2296
Practice Address - Street 1:123 WESTMARK BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-7345
Practice Address - Country:US
Practice Address - Phone:337-255-0950
Practice Address - Fax:337-466-2296
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-478103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst