Basic Information
Provider Information | |||||||||
NPI: | 1407356538 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | TAYLOR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FELDMANN | ||||||||
OtherFirstName: | TAYLOR | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 15074 TESORO DR | ||||||||
Address2: |   | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784186942 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2104228291 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1533 S BROWNLEE BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784043131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3618842242 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2018 | ||||||||
LastUpdateDate: | 02/15/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 70633 | 01 | TX | LICSENCE | OTHER |