Provider Demographics
NPI:1497246623
Name:TAKKE, KARYN COPPOCK
Entity Type:Individual
Prefix:
First Name:KARYN
Middle Name:COPPOCK
Last Name:TAKKE
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 1:758 W 2100 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1240
Mailing Address - Country:US
Mailing Address - Phone:801-918-9053
Mailing Address - Fax:
Practice Address - Street 1:1465 W CENTER ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5104
Practice Address - Country:US
Practice Address - Phone:801-224-2968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health