Provider Demographics
NPI:1780175158
Name:TAYLOR, AJA ANTREA
Entity type:Individual
Prefix:MS
First Name:AJA
Middle Name:ANTREA
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 1:1219 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2405
Mailing Address - Country:US
Mailing Address - Phone:352-323-0612
Mailing Address - Fax:352-787-2386
Practice Address - Street 1:1300 CITIZENS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3973
Practice Address - Country:US
Practice Address - Phone:352-323-0612
Practice Address - Fax:352-787-2386
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker