Provider Demographics
NPI:1548304215
Name:GILL-TAYLOR, ANGELA S (PSYD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:GILL-TAYLOR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:855-420-7900
Mailing Address - Fax:
Practice Address - Street 1:1312 E LARK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7351
Practice Address - Country:US
Practice Address - Phone:417-820-3707
Practice Address - Fax:417-820-7954
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003030076103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO82773OtherAR BLUE SHIELD #
MO499115608Medicaid
MO82773OtherAR BLUE SHIELD #