MEDICARE: MRS. CASEY MYRIAH TAYLOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	33900	CA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1811440845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CASEY MYRIAH TAYLOR

Provider Business Mailing Address
First Line	:	1650 51ST ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-4504
Country	:	US
Telephone Number	:	336-409-9479
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 51ST ST
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95819-4504
Country	:	US
Telephone Number	:	336-409-9479
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	12/21/2022

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