=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184296477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR NICOLE LOGGINS LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2021
-----------------------------------------------------
Last Update Date | 07/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 690 COURTENAY DR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30306-3421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-875-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 RAGAN DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30157-0743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-637-4282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | MSW009484
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------