Healthcare Provider Details

I. General information

NPI: 1417445578
Provider Name (Legal Business Name): ANDRE CARDRELL TAYLOR CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FREDERICK AVE
AKRON OH
44310-2904
US

IV. Provider business mailing address

1251 WEATHERVANE LN APT 3A
AKRON OH
44313-5167
US

V. Phone/Fax

Practice location:
  • Phone: 330-996-7730
  • Fax:
Mailing address:
  • Phone: 440-541-2161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number166211
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: