Healthcare Provider Details

I. General information

NPI: 1679623763
Provider Name (Legal Business Name): EVELYN LORISA TAYLOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 HWY 69 WEST
TRUMANN AR
72472-2029
US

IV. Provider business mailing address

1815 PLEASANT GROVE RD
JONESBORO AR
72401-7870
US

V. Phone/Fax

Practice location:
  • Phone: 870-483-4003
  • Fax: 870-483-4009
Mailing address:
  • Phone: 870-933-6886
  • Fax: 870-933-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW0000004502
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7144-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: