Healthcare Provider Details

I. General information

NPI: 1679465959
Provider Name (Legal Business Name): TAYLOR LOCKRIDGE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22206 W WARREN AVE
REDFORD MI
48239-1024
US

IV. Provider business mailing address

22430 GRATIOT AVE UNIT 227
EASTPOINTE MI
48021-7011
US

V. Phone/Fax

Practice location:
  • Phone: 313-804-8635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: