Healthcare Provider Details

I. General information

NPI: 1962401836
Provider Name (Legal Business Name): MARY A TAYLOR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BLANTON AVE STE 102
RICHMOND VA
23221-3603
US

IV. Provider business mailing address

1605 WHITE CEDAR LN
N CHESTERFLD VA
23235-5449
US

V. Phone/Fax

Practice location:
  • Phone: 804-621-2650
  • Fax: 804-276-8195
Mailing address:
  • Phone: 804-621-2650
  • Fax: 804-748-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090400430
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: