Provider Demographics
NPI:1033275375
Name:TAKEUCHI, RISA
Entity Type:Individual
Prefix:
First Name:RISA
Middle Name:
Last Name:TAKEUCHI
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 1:21151 S WESTERN AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-1724
Mailing Address - Country:US
Mailing Address - Phone:323-591-9611
Mailing Address - Fax:
Practice Address - Street 1:21151 S WESTERN AVE STE 206
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-1724
Practice Address - Country:US
Practice Address - Phone:323-591-9611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 390200000X
CAPSB94024733101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No251S00000XAgenciesCommunity/Behavioral Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38BF3Medicaid