Healthcare Provider Details

I. General information

NPI: 1366930760
Provider Name (Legal Business Name): TAYLOR LAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6421 ATWOOD ST
DISTRICT HEIGHTS MD
20747-1345
US

IV. Provider business mailing address

6421 ATWOOD ST
DISTRICT HEIGHTS MD
20747-1345
US

V. Phone/Fax

Practice location:
  • Phone: 301-336-7600
  • Fax: 301-499-2121
Mailing address:
  • Phone: 301-336-7600
  • Fax: 301-499-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC14912
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: