Provider Demographics
NPI:1912486069
Name:TAYLOR, RICKI ALEXIS
Entity Type:Individual
Prefix:
First Name:RICKI
Middle Name:ALEXIS
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 1:5720 S LAKESHORE DR APT 307
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-3929
Mailing Address - Country:US
Mailing Address - Phone:913-293-9437
Mailing Address - Fax:
Practice Address - Street 1:5720 S LAKESHORE DR APT 307
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-3929
Practice Address - Country:US
Practice Address - Phone:913-293-9437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSK03-71-2148101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSK03-71-2148Medicaid