Provider Demographics
NPI:1861968638
Name:TAYLOR, ANDREA LEENETTE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEENETTE
Last Name:TAYLOR
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 1:24166 TRAFALGAR CT
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-3667
Mailing Address - Country:US
Mailing Address - Phone:248-497-1001
Mailing Address - Fax:
Practice Address - Street 1:24166 TRAFALGAR CT
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-3667
Practice Address - Country:US
Practice Address - Phone:248-497-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009648101Y00000X
MI6301019134103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor