Provider Demographics
NPI:1225474000
Name:TAKACH, LAURA LEIGH (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LEIGH
Last Name:TAKACH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SOARING EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:FISCHER
Mailing Address - State:TX
Mailing Address - Zip Code:78623-1809
Mailing Address - Country:US
Mailing Address - Phone:830-708-1256
Mailing Address - Fax:
Practice Address - Street 1:8103 NORTH HOLW
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-2387
Practice Address - Country:US
Practice Address - Phone:210-558-9001
Practice Address - Fax:210-558-9010
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207982172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker