Healthcare Provider Details

I. General information

NPI: 1609401298
Provider Name (Legal Business Name): MISS PAMELA TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7611 S CRANDON AVE
CHICAGO IL
60649-4116
US

IV. Provider business mailing address

7611 S CRANDON AVE
CHICAGO IL
60649-4116
US

V. Phone/Fax

Practice location:
  • Phone: 773-510-4909
  • Fax:
Mailing address:
  • Phone: 773-510-4909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: