MEDICARE: MR. TAYLOR SELF LCMHC, LCAS

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	11100	NC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-21523	NC

General Provider Information

NPI Number	:	1871928705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TAYLOR SELF LCMHC, LCAS

Provider Business Mailing Address
First Line	:	5200 PARAMOUNT PKWY STE 200
Second Line	:
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-5470
Country	:	US
Telephone Number	:	919-651-8401
Fax Number	:

Provider Business Practice Location Address
First Line	:	5200 PARAMOUNT PKWY STE 200
Second Line	:
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-5470
Country	:	US
Telephone Number	:	919-651-8401
Fax Number	:

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

Provider Enumeration Date	:	09/11/2013
Last Update Date	:	01/22/2022

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