Basic Information
| Provider Information | |||||||||
| NPI: | 1619500162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | TISHANNA | ||||||||
| MiddleName: | MAYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9737 ROLAN MEADOWS DR | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481118103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134565062 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 37450 SCHOOLCRAFT RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344584601 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2020 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.