Provider Demographics
NPI:1295117182
Name:TAKETA, SHELLY (MS, ATC)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:TAKETA
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1928 SAINT MARYS RD
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94575-2715
Mailing Address - Country:US
Mailing Address - Phone:925-876-7347
Mailing Address - Fax:
Practice Address - Street 1:1928 SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94575-2715
Practice Address - Country:US
Practice Address - Phone:925-876-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer