Provider Demographics
NPI:1780729533
Name:TAKEMOTO, SUE ANN MICHI (MSW)
Entity type:Individual
Prefix:MRS
First Name:SUE ANN
Middle Name:MICHI
Last Name:TAKEMOTO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MICHI
Other - Middle Name:
Other - Last Name:TAKEMOTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:195 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0907
Mailing Address - Country:US
Mailing Address - Phone:530-241-1716
Mailing Address - Fax:
Practice Address - Street 1:2485 OLD EUREKA WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0336
Practice Address - Country:US
Practice Address - Phone:530-355-5131
Practice Address - Fax:530-244-1546
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS108971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-CMedicare UPIN