MEDICARE: KEITH ANTHONY 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	101YM0800X	Mental Health Counselor
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1760606446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH ANTHONY TAYLOR

Provider Business Mailing Address
First Line	:	1028 SIERRA BLVD # 1
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-2900
Country	:	US
Telephone Number	:	530-573-7800
Fax Number	:	530-542-7041

Provider Business Practice Location Address
First Line	:	768 PLEASANT VALLEY RD
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9260
Country	:	US
Telephone Number	:	530-621-6245
Fax Number	:	530-542-7041

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	06/28/2023

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