Provider Demographics
NPI:1770065740
Name:KINGHAM, TAYLER ELYZABETH
Entity type:Individual
Prefix:
First Name:TAYLER
Middle Name:ELYZABETH
Last Name:KINGHAM
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 1:2511 CORTEZ CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3414
Mailing Address - Country:US
Mailing Address - Phone:806-881-5098
Mailing Address - Fax:
Practice Address - Street 1:2511 CORTEZ CT
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3414
Practice Address - Country:US
Practice Address - Phone:806-881-5098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician