Healthcare Provider Details

I. General information

NPI: 1639634868
Provider Name (Legal Business Name): TAYLOR PAIGE TADLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 N BRAGG BLVD
SPRING LAKE NC
28390-3316
US

IV. Provider business mailing address

1018 N BRAGG BLVD
SPRING LAKE NC
28390-3316
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-2609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberRBT-19-77043
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: