Healthcare Provider Details

I. General information

NPI: 1386923126
Provider Name (Legal Business Name): MRS. TRACY BELL TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 03/07/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 MALABAR RD SE STE 111-112
PALM BAY FL
32907-3239
US

IV. Provider business mailing address

1150 MALABAR RD SE STE 111-112
PALM BAY FL
32907-3239
US

V. Phone/Fax

Practice location:
  • Phone: 772-469-6466
  • Fax: 888-419-1172
Mailing address:
  • Phone: 772-469-6466
  • Fax: 888-419-1172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH15656
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17900
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: