Provider Demographics
NPI:1629238712
Name:TAKATA, CHRISTINE L
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:L
Last Name:TAKATA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CHRISTINE
Other - Middle Name:L
Other - Last Name:HONEA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2825 TUOLUMNE PL UNIT F
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0167
Mailing Address - Country:US
Mailing Address - Phone:909-947-5687
Mailing Address - Fax:
Practice Address - Street 1:160 E HOLT AVE STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5407
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW1713101YA0400X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)