Provider Demographics
NPI:1548735459
Name:BERUBE, TAYLOR MARIE
Entity type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:MARIE
Last Name:BERUBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 THOROUGHBRED CIR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5838
Mailing Address - Country:US
Mailing Address - Phone:630-901-9493
Mailing Address - Fax:
Practice Address - Street 1:140 N WRIGHT ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-4748
Practice Address - Country:US
Practice Address - Phone:630-355-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-06
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-18-31669103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst