=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447677927
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANGENIQUE TAYLOR OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2014
-----------------------------------------------------
Last Update Date | 10/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2786 N DECATUR RD STE 230
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-5928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-289-4270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3961 FLOYD ROAD STE 300 225
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-0341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-530-9012
-----------------------------------------------------
Fax | 770-234-4243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT005635
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------