Provider Demographics
NPI:1053782359
Name:TAYLOR, THERESA ANN BRIDGET (LMSW, SAP, SUDRC)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN BRIDGET
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LMSW, SAP, SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7545 METROPOLITAN DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4402
Practice Address - Country:US
Practice Address - Phone:619-718-9890
Practice Address - Fax:619-718-9897
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8628101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)