Provider Demographics
NPI:1669235420
Name:TAKATA, SYDNEY CHRISTINE
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:CHRISTINE
Last Name:TAKATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107A LAURA LN
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-7900
Mailing Address - Country:US
Mailing Address - Phone:773-706-0207
Mailing Address - Fax:
Practice Address - Street 1:73 EAKES DR
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-7900
Practice Address - Country:US
Practice Address - Phone:773-706-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260037852255A2300X
NCLAT-57032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer