Provider Demographics
NPI:1891856449
Name:TAKESIAN, AMY MALLOY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:MALLOY
Last Name:TAKESIAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:ROYERSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19468-1872
Mailing Address - Country:US
Mailing Address - Phone:617-285-2316
Mailing Address - Fax:
Practice Address - Street 1:1516 BROOKE DR
Practice Address - Street 2:
Practice Address - City:ROYERSFORD
Practice Address - State:PA
Practice Address - Zip Code:19468-1872
Practice Address - Country:US
Practice Address - Phone:617-285-2316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019407103TC0700X
MA8789103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical