Provider Demographics
NPI:1932596731
Name:BENN, TAKAKO
Entity Type:Individual
Prefix:
First Name:TAKAKO
Middle Name:
Last Name:BENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAKAKO
Other - Middle Name:
Other - Last Name:OGASAWARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:251 E MERRILL ST
Mailing Address - Street 2:STE 230
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6116
Mailing Address - Country:US
Mailing Address - Phone:248-949-0484
Mailing Address - Fax:
Practice Address - Street 1:3901 CHRYSLER SERVICE DR
Practice Address - Street 2:SUITE 5-A, 538.4
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-577-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFS23985102084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program