Basic Information
| Provider Information | |||||||||
| NPI: | 1811419435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPHA, LCPC, CRC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 904 E. MARTIN LUTHER KING DRIVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185331391 | ||||||||
| FaxNumber: | 6185330012 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 E. MARTIN LUTHER KING DRIVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185331391 | ||||||||
| FaxNumber: | 6185330012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180003710 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 370915481007 | 05 | IL | MEDICAID |