Healthcare Provider Details

I. General information

NPI: 1760689574
Provider Name (Legal Business Name): AVIS M TAYLOR MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 S COMMERCE
ARDMORE OK
73401
US

IV. Provider business mailing address

415 WILLOWRIDGE ST APT I7
ARDMORE OK
73401-2258
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5636
  • Fax:
Mailing address:
  • Phone: 580-223-5636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2437
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: