Basic Information
| Provider Information | |||||||||
| NPI: | 1245878354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | JOHNNIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 HAMPSHIRE DR | ||||||||
| Address2: | |||||||||
| City: | DEPTFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080964208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095567607 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 42 DELSEA DR S | ||||||||
| Address2: | |||||||||
| City: | GLASSBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080282621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444223632 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2019 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.