Provider Demographics
NPI:1093390387
Name:TAKARA, RISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:RISA
Middle Name:
Last Name:TAKARA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:RISA
Other - Middle Name:
Other - Last Name:TAKARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:363 E 1200 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6904
Mailing Address - Country:US
Mailing Address - Phone:801-224-2313
Mailing Address - Fax:
Practice Address - Street 1:363 E 1200 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6904
Practice Address - Country:US
Practice Address - Phone:801-224-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8772962-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist