Basic Information
Provider Information | |||||||||
NPI: | 1629238712 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAKATA | ||||||||
FirstName: | CHRISTINE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HONEA | ||||||||
OtherFirstName: | CHRISTINE | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2825 TUOLUMNE PL UNIT F | ||||||||
Address2: |   | ||||||||
City: | ONTARIO | ||||||||
State: | CA | ||||||||
PostalCode: | 917610167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099475687 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 160 E HOLT AVE STE B | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917675407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9096202521 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2008 | ||||||||
LastUpdateDate: | 06/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RW1713 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 225400000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   |
No ID Information.