=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518185289
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN KEITH TAYLOR SCHOOL PSYCHOLOGIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4417 N 66TH AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85033-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-691-4518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6755 E JUNIPER AVE
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85254-5643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-221-7328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 1849257
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------