Healthcare Provider Details

I. General information

NPI: 1205438769
Provider Name (Legal Business Name): TAYLOR CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 JAMES ST
SEATTLE WA
98104-5102
US

IV. Provider business mailing address

515 3RD AVE
SEATTLE WA
98104-2321
US

V. Phone/Fax

Practice location:
  • Phone: 206-464-6454
  • Fax:
Mailing address:
  • Phone: 206-464-1570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61035195
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: