Basic Information
| Provider Information | |||||||||
| NPI: | 1063945905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LSW, CDCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FISHER | ||||||||
| OtherFirstName: | AMY | ||||||||
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| OtherCredential: | CDCA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 441 DAVIS RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071121 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2017 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
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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 | 101YA0400X | CDCA.140934 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | S.1701597 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.