Healthcare Provider Details

I. General information

NPI: 1750540852
Provider Name (Legal Business Name): AL CHARLESTON TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 LEA DR
SAN RAFAEL CA
94903-3746
US

IV. Provider business mailing address

1380 HOWARD ST
SAN FRANCISCO CA
94103-2638
US

V. Phone/Fax

Practice location:
  • Phone: 510-575-1179
  • Fax:
Mailing address:
  • Phone: 510-575-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number98721
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number98721
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number98721
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: