1891113940 NPI number — MRS. GILLIAN DECLARK TAYLOR MA, LCPC

Table of content: MRS. GILLIAN DECLARK TAYLOR MA, LCPC (NPI 1891113940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891113940 NPI number — MRS. GILLIAN DECLARK TAYLOR MA, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
GILLIAN
Provider Middle Name:
DECLARK
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DECLARK
Provider Other First Name:
GILLIAN
Provider Other Middle Name:
DRAPER
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891113940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2653 W OGDEN AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60608-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-257-5312
Provider Business Mailing Address Fax Number:
773-257-5330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2653 W OGDEN AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60608-1647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-257-5312
Provider Business Practice Location Address Fax Number:
773-257-5330
Provider Enumeration Date:
04/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  180.008695 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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