Healthcare Provider Details

I. General information

NPI: 1295066314
Provider Name (Legal Business Name): TINA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2010
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3192 GLEN CANYON RD
SCOTTS VALLEY CA
95066-4916
US

IV. Provider business mailing address

3600 GLEN CANYON RD
SCOTTS VALLEY CA
95066-4923
US

V. Phone/Fax

Practice location:
  • Phone: 831-438-1868
  • Fax:
Mailing address:
  • Phone: 831-438-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC052040418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: