Provider Demographics
NPI:1952759334
Name:TAYLOR, SHELLEY (LISAC)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 WILLOW CREEK RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1124
Mailing Address - Country:US
Mailing Address - Phone:928-445-0744
Mailing Address - Fax:928-445-0537
Practice Address - Street 1:1660 WILLOW CREEK RD
Practice Address - Street 2:SUITE A
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1124
Practice Address - Country:US
Practice Address - Phone:928-445-0744
Practice Address - Fax:928-445-0537
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10987101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)