Healthcare Provider Details

I. General information

NPI: 1104062785
Provider Name (Legal Business Name): CARLISSA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 12TH ST
COLUMBUS GA
31901-2522
US

IV. Provider business mailing address

13 SADDLE LN
PHENIX CITY AL
36869-6167
US

V. Phone/Fax

Practice location:
  • Phone: 706-494-7776
  • Fax: 706-494-7072
Mailing address:
  • Phone: 706-332-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: