Provider Demographics
NPI:1861106718
Name:THALACKER, TAYLOR (LMHC)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:THALACKER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 7TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3632
Mailing Address - Country:US
Mailing Address - Phone:352-362-6614
Mailing Address - Fax:
Practice Address - Street 1:6013 BRANDON CIR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3834
Practice Address - Country:US
Practice Address - Phone:813-413-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20458101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health