Basic Information
| Provider Information | |||||||||
| NPI: | 1003396169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 INTERSTATE 10 N STE 225 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777072549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098350228 | ||||||||
| FaxNumber: | 4098350151 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 INTERSTATE 10 N STE 225 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777072549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098350228 | ||||||||
| FaxNumber: | 4098350151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 101606 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.