MEDICARE: DESREE IVY TAYLOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-26-88311	CA

General Provider Information

NPI Number	:	1205588217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESREE IVY TAYLOR

Provider Business Mailing Address
First Line	:	295 89TH ST
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94015-1653
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	295 89TH ST
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94015-1653
Country	:	US
Telephone Number	:	877-264-6747
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2022
Last Update Date	:	03/31/2026

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