Provider Demographics
NPI:1841701406
Name:LONG, TAYLOR MICHELLE (MED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WIND HAVEN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8010
Mailing Address - Country:US
Mailing Address - Phone:859-224-2273
Mailing Address - Fax:859-224-4675
Practice Address - Street 1:117 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1764
Practice Address - Country:US
Practice Address - Phone:859-224-2273
Practice Address - Fax:859-224-4675
Is Sole Proprietor?:No
Enumeration Date:2017-10-22
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA1-20-45592103K00000X
KY271557103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-45592OtherBCBA CERTIFICATE