Healthcare Provider Details

I. General information

NPI: 1194023168
Provider Name (Legal Business Name): KIM VICTORIA TAYLOR LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 CAMBRIDGE PL
SMITHFIELD NC
27577-4717
US

IV. Provider business mailing address

109 CAMBRIDGE PL
SMITHFIELD NC
27577-4717
US

V. Phone/Fax

Practice location:
  • Phone: 919-989-8114
  • Fax: 919-938-0503
Mailing address:
  • Phone: 919-989-8114
  • Fax: 919-938-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP-005960
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1774
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: