Provider Demographics
NPI:1235971433
Name:HENRY TAYLOR, PATRICIA AVA-GAY-E TANISH I
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:AVA-GAY-E TANISH
Last Name:HENRY TAYLOR
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12531 CLIPPER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2355
Mailing Address - Country:US
Mailing Address - Phone:517-398-0428
Mailing Address - Fax:
Practice Address - Street 1:12531 CLIPPER DR STE 201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2355
Practice Address - Country:US
Practice Address - Phone:517-398-0428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-23-31804106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician