Provider Demographics
NPI:1871144758
Name:ANDERSON, TAYTIANA
Entity type:Individual
Prefix:
First Name:TAYTIANA
Middle Name:
Last Name:ANDERSON
Suffix:
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 1:11892 MCCRUMB DR
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80233-1231
Mailing Address - Country:US
Mailing Address - Phone:720-253-4902
Mailing Address - Fax:
Practice Address - Street 1:11892 MCCRUMB DR
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233-1231
Practice Address - Country:US
Practice Address - Phone:720-253-4902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COBACB515641405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional