Provider Demographics
NPI:1508885500
Name:TAKESHITA, TRACIE L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:L
Last Name:TAKESHITA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 PUNAHOU ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-3336
Mailing Address - Country:US
Mailing Address - Phone:808-944-5711
Mailing Address - Fax:
Practice Address - Street 1:1601 PUNAHOU ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96822-3336
Practice Address - Country:US
Practice Address - Phone:808-944-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY 912103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical