Basic Information
| Provider Information | |||||||||
| NPI: | 1720163983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1874 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Practice Location | |||||||||
| Address1: | 1874 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SW830 | FL | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | Z154G | 01 | FL | FLORIDA BCBS | OTHER | AK132Z | 01 | FL | FLORIDA MEDICARE MFAA-COASTAL PAIN LINKED TO 33576B | OTHER |