Healthcare Provider Details

I. General information

NPI: 1871928705
Provider Name (Legal Business Name): TAYLOR SELF LCMHC, LCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 01/22/2022
Certification Date: 01/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 PARAMOUNT PKWY STE 200
MORRISVILLE NC
27560-5470
US

IV. Provider business mailing address

5200 PARAMOUNT PKWY STE 200
MORRISVILLE NC
27560-5470
US

V. Phone/Fax

Practice location:
  • Phone: 919-651-8401
  • Fax:
Mailing address:
  • Phone: 919-651-8401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-21523
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11100
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: