Healthcare Provider Details

I. General information

NPI: 1083869127
Provider Name (Legal Business Name): MARISSA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

IV. Provider business mailing address

5848 US HIGHWAY 82 W
CUTHBERT GA
39840-2956
US

V. Phone/Fax

Practice location:
  • Phone: 706-596-5583
  • Fax: 706-596-5589
Mailing address:
  • Phone: 229-364-4496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: