Healthcare Provider Details

I. General information

NPI: 1306403852
Provider Name (Legal Business Name): TAYLOR PINKHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAYLOR POTRZEBOWSKI

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 SAINT JOSEPH DR
BLOOMINGTON IL
61701-3638
US

IV. Provider business mailing address

507 E ARMSTRONG AVE
PEORIA IL
61603-3201
US

V. Phone/Fax

Practice location:
  • Phone: 309-386-1177
  • Fax:
Mailing address:
  • Phone: 309-686-1177
  • Fax: 309-686-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-60334
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-105973
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: