Healthcare Provider Details

I. General information

NPI: 1942256805
Provider Name (Legal Business Name): KRISTIN WILSON TAYLOR LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WAREHAM ST
CARVER MA
02330-1716
US

IV. Provider business mailing address

55 WAREHAM ST
CARVER MA
02330-1716
US

V. Phone/Fax

Practice location:
  • Phone: 508-280-4825
  • Fax:
Mailing address:
  • Phone: 508-280-4825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMA111382
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: