Provider Demographics
NPI:1144855784
Name:TAYLOR., MARILYN LOUSIE (LLPC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:LOUSIE
Last Name:TAYLOR.
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31581 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4528
Mailing Address - Country:US
Mailing Address - Phone:586-783-4802
Mailing Address - Fax:
Practice Address - Street 1:31581 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4528
Practice Address - Country:US
Practice Address - Phone:586-783-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401016800Medicaid