Provider Demographics
NPI:1851401970
Name:TAKEUCHI, SHIGERU (ATC)
Entity Type:Individual
Prefix:
First Name:SHIGERU
Middle Name:
Last Name:TAKEUCHI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CRAWFORD ST APT 317
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4660
Mailing Address - Country:US
Mailing Address - Phone:812-237-7423
Mailing Address - Fax:
Practice Address - Street 1:ATHLETIC TRAINING DEPARTMENT
Practice Address - Street 2:INDIANA STATE UNIVERSITY
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-0001
Practice Address - Country:US
Practice Address - Phone:812-237-9613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001300A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer