Provider Demographics
NPI:1154488344
Name:TAKAGISHI, COLLEEN MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MICHELLE
Last Name:TAKAGISHI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:DIVISION OF HEMATOLOGY-ONCOLOGY
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:888-909-5222
Practice Address - Fax:847-570-2336
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
164-000805133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164-000805OtherIL STATE LIC