Provider Demographics
NPI:1700265188
Name:PHELPS-WHITLEY, TAYLOR MARIE (LSW)
Entity type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:MARIE
Last Name:PHELPS-WHITLEY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:MRS
Other - First Name:TAYLOR
Other - Middle Name:MAIRE
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:1879 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9946
Mailing Address - Country:US
Mailing Address - Phone:513-695-2900
Mailing Address - Fax:513-695-2961
Practice Address - Street 1:1879 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9946
Practice Address - Country:US
Practice Address - Phone:513-695-2900
Practice Address - Fax:513-695-2961
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OHS1500912251S00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0281171Medicaid