Provider Demographics
NPI:1013941244
Name:TAKAGISHI, STANLEY CURTIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:CURTIS
Last Name:TAKAGISHI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10411 LIGHTNER BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1815
Mailing Address - Country:US
Mailing Address - Phone:813-690-5806
Mailing Address - Fax:
Practice Address - Street 1:13701 BRUCE B DOWNS BLVD STE 111
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4647
Practice Address - Country:US
Practice Address - Phone:813-690-8506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6420103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
54739Medicare ID - Type Unspecified