Basic Information
| Provider Information | |||||||||
| NPI: | 1528475225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | THERESSA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LAC, CRC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728012816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706471400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1310 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728012816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706471400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2014 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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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 | 101YM0800X | A1407092 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.