Provider Demographics
NPI:1710075338
Name:TAKETOMO, RENEE RUSSIAN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:RUSSIAN
Last Name:TAKETOMO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-6441
Mailing Address - Country:US
Mailing Address - Phone:781-641-1452
Mailing Address - Fax:781-641-4515
Practice Address - Street 1:48 IRVING ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-6441
Practice Address - Country:US
Practice Address - Phone:781-641-1452
Practice Address - Fax:781-641-4515
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1001681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MATAP01908OtherBLUECROSS/BLUESHIELD
MAPO1908Medicare ID - Type Unspecified