Healthcare Provider Details

I. General information

NPI: 1407774540
Provider Name (Legal Business Name): TERESA L TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERRY TAYLOR

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N KELLER ST
REPUBLIC WA
99166
US

IV. Provider business mailing address

165 E HAWTHORNE AVE
COLVILLE WA
99114-2629
US

V. Phone/Fax

Practice location:
  • Phone: 509-775-3341
  • Fax:
Mailing address:
  • Phone: 509-684-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCAAR.CG.70148266
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: