Provider Demographics
NPI:1053057802
Name:PRINCE, TAYLER
Entity type:Individual
Prefix:
First Name:TAYLER
Middle Name:
Last Name:PRINCE
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 1:1947 GALILEO CT STE 101
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4882
Mailing Address - Country:US
Mailing Address - Phone:530-220-1450
Mailing Address - Fax:
Practice Address - Street 1:111 DEERWOOD RD STE 115
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4445
Practice Address - Country:US
Practice Address - Phone:949-325-4402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician