Healthcare Provider Details

I. General information

NPI: 1558015230
Provider Name (Legal Business Name): TAYLOR VICKERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 DAIRY RD STE 108
MELBOURNE FL
32904-7630
US

IV. Provider business mailing address

1725 NANTUCKETT LN APT 208
CHARLOTTE NC
28270-3318
US

V. Phone/Fax

Practice location:
  • Phone: 813-219-3311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: