MEDICARE: MR. MELVIN TAYLOR LISAC

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	101Y00000X	Counselor	1229	AZ
2	101YM0800X	Mental Health Counselor	10612	AZ
3	104100000X	Social Worker	10612	AZ

General Provider Information

NPI Number	:	1871678821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MELVIN TAYLOR LISAC

Provider Business Mailing Address
First Line	:	288 N IRONWOOD DR STE 110
Second Line	:	SAN TAN COUNSELING
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-3830
Country	:	US
Telephone Number	:	480-982-2356
Fax Number	:	480-982-0859

Provider Business Practice Location Address
First Line	:	288 N IRONWOOD DR STE 110
Second Line	:	SAN TAN COUNSELING
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85220-3830
Country	:	US
Telephone Number	:	480-982-2356
Fax Number	:	480-982-0859

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	11/19/2007

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