=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376870022
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAIR TAYLOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2009
-----------------------------------------------------
Last Update Date | 11/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 MEDICAL BLVD
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-7230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-264-0357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 THAGARD DR
-----------------------------------------------------
City | PETAL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39465-9604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 3159
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------