Provider Demographics
NPI:1861956815
Name:TAYLOR, GUY O SR
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:O
Last Name:TAYLOR
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10343 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2410
Mailing Address - Country:US
Mailing Address - Phone:916-470-1816
Mailing Address - Fax:
Practice Address - Street 1:10343 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2410
Practice Address - Country:US
Practice Address - Phone:916-470-1816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30264167G00000X
103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician