Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 2882 | WI |
NPI | 1003812157 |
---|---|
Provider Name | Mark L Taylor |
First Address | La Crosse, WI 54601-5467 |
Second Address | La Crosse, WI 54601-5467 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39788100 | (05) | WI |