Provider Demographics
NPI:1730685512
Name:NIESE, TAYLOR (LSW)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:NIESE
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5267
Mailing Address - Country:US
Mailing Address - Phone:419-330-5122
Mailing Address - Fax:
Practice Address - Street 1:6359 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1547
Practice Address - Country:US
Practice Address - Phone:419-890-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
IN33010502A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health