Healthcare Provider Details

I. General information

NPI: 1144731407
Provider Name (Legal Business Name): TAYLOR JANINE RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1284 DEVIN OAKS CT
LAKELAND FL
33811-2383
US

IV. Provider business mailing address

PO BOX 6553
LAKELAND FL
33807-6553
US

V. Phone/Fax

Practice location:
  • Phone: 863-602-0698
  • Fax: 813-354-2715
Mailing address:
  • Phone: 863-602-0698
  • Fax: 813-354-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-37687
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-17-7917
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: