Provider Demographics
NPI:1023741063
Name:SMITH, TAYLOR SAVANNAH
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:SAVANNAH
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUNO
Other - Middle Name:SAVANNAH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:810-599-2129
Mailing Address - Fax:
Practice Address - Street 1:300 SAINT ANDREWS RD STE 407
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-5977
Practice Address - Country:US
Practice Address - Phone:989-401-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician