Provider Demographics
NPI:1659631349
Name:TAKATA, MARTHA SUE (AUD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:SUE
Last Name:TAKATA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 QUEBEC AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4023
Mailing Address - Country:US
Mailing Address - Phone:952-935-8571
Mailing Address - Fax:
Practice Address - Street 1:5808 W 36TH ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5108
Practice Address - Country:US
Practice Address - Phone:952-767-0672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8928231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist