1417521360 NPI number — CHRISTEN NICOLE TAKACS LPC

Table of content: CHRISTEN NICOLE TAKACS LPC (NPI 1417521360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417521360 NPI number — CHRISTEN NICOLE TAKACS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAKACS
Provider First Name:
CHRISTEN
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417521360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 CLEVELAND AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44702-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-455-0374
Provider Business Mailing Address Fax Number:
330-453-6716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 1ST ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASSILLON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44647-5452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-833-0234
Provider Business Practice Location Address Fax Number:
330-837-7705
Provider Enumeration Date:
05/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  C.2204382 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0450780 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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