=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972118487
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY T TAYLOR LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2020
-----------------------------------------------------
Last Update Date | 09/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17148 LIBRARY BLVD
-----------------------------------------------------
City | RUTHER GLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22546-5809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-994-4785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8535
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22404-8535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-994-4785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904012292
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------