Provider Demographics
NPI:1710037387
Name:GOTTSCHALK, TAKANA ARIELA (QMHW)
Entity Type:Individual
Prefix:
First Name:TAKANA
Middle Name:ARIELA
Last Name:GOTTSCHALK
Suffix:
Gender:F
Credentials:QMHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15408
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-5408
Mailing Address - Country:US
Mailing Address - Phone:805-328-4509
Mailing Address - Fax:805-934-2182
Practice Address - Street 1:812 W FOSTER RD
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-3511
Practice Address - Country:US
Practice Address - Phone:805-928-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health