MEDICARE: TAYLOR LAKE

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	101YP2500X	Professional Counselor	LC14912	MD
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1366930760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR LAKE

Provider Business Mailing Address
First Line	:	6421 ATWOOD ST
Second Line	:
City	:	DISTRICT HEIGHTS
State	:	MD
Zip	:	20747-1345
Country	:	US
Telephone Number	:	301-336-7600
Fax Number	:	301-499-2121

Provider Business Practice Location Address
First Line	:	6421 ATWOOD ST
Second Line	:
City	:	DISTRICT HEIGHTS
State	:	MD
Zip	:	20747-1345
Country	:	US
Telephone Number	:	301-336-7600
Fax Number	:	301-499-2121

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

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	02/18/2026

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Directions to “ TAYLOR LAKE ” Practice Location

Language	Start Address	Practice Location

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