Provider Demographics
NPI:1184267759
Name:LEISHER, TAYLOR GLEN SHIGERU KEOKI
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:GLEN SHIGERU KEOKI
Last Name:LEISHER
Suffix:
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 1:862 N MARSHFIELD AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5137
Mailing Address - Country:US
Mailing Address - Phone:847-208-0007
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE STE 1609
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3652
Practice Address - Country:US
Practice Address - Phone:773-683-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL178015953101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty