Basic Information
| Provider Information | |||||||||
| NPI: | 1275860462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | MA EDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877936 | ||||||||
| FaxNumber: | 3044877835 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 SOUTHVIEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247014317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043254673 | ||||||||
| FaxNumber: | 3043279210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 0 | WV | N | Behavioral Health & Social Service Providers | Psychologist | School | 103TC0700X | 997 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 997 | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TB0200X | 997 | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC1900X | 997 | WV | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TF0000X | 997 | N | Behavioral Health & Social Service Providers | Psychologist | Family | 103TF0200X | 997 | N | Behavioral Health & Social Service Providers | Psychologist | Forensic | 106H00000X | 997 | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103TF0200X | 997 | WV | N | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TP2701X | 997 | WV | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TM1800X | 997 | WV | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103T00000X | 997 | WV | N | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 3810016308 | 05 | WV | MEDICAID |