Provider Demographics
NPI:1942409156
Name:TAKESUE, CORI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CORI
Middle Name:
Last Name:TAKESUE
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:PO BOX 631261
Mailing Address - Street 2:
Mailing Address - City:LANAI CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96763-1261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 SIXTH STREET
Practice Address - Street 2:
Practice Address - City:LANAI CITY
Practice Address - State:HI
Practice Address - Zip Code:96763
Practice Address - Country:US
Practice Address - Phone:808-565-6919
Practice Address - Fax:808-565-9111
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-1861103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist