Provider Demographics
NPI:1881930410
Name:TAYLOR, LATISHA
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:
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 1:69 WOODFORD ST
Mailing Address - Street 2:#2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2769
Practice Address - Country:US
Practice Address - Phone:617-989-9499
Practice Address - Fax:617-445-2672
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS56106257101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor