Basic Information
| Provider Information | |||||||||
| NPI: | 1194023168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | VICATORIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 CAMBRIDGE PL | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199898114 | ||||||||
| FaxNumber: | 9199380503 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 CAMBRIDGE PL | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275774717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199898114 | ||||||||
| FaxNumber: | 9199380503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2011 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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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 | 1041C0700X | P-005960 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 1774 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.