Basic Information
| Provider Information | |||||||||
| NPI: | 1225697667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SZEWCYK | ||||||||
| FirstName: | TAYLOR | ||||||||
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| Credential: | CT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8445 MUNSON RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440602410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402551700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8445 MUNSON RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440602410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402551700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2019 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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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 | 251S00000X | C.1901687-TRNE | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2864093 | 05 | OH | MEDICAID |