=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639743024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR MARIE SUTTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2021
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 S MAIN ST STE 100
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-4283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-244-8782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 20TH ST NE
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44714-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-545-0515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C.2103255-TRNE
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------