Provider Demographics
NPI:1184271199
Name:TAYLOR, MCKENSIE RENEE (MT-BC)
Entity type:Individual
Prefix:MRS
First Name:MCKENSIE
Middle Name:RENEE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11730 MOUNTAIN PARK RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1819
Mailing Address - Country:US
Mailing Address - Phone:678-392-6355
Mailing Address - Fax:
Practice Address - Street 1:12060 ETRIS RD STE 200
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-1463
Practice Address - Country:US
Practice Address - Phone:678-701-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15308225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist