Healthcare Provider Details

I. General information

NPI: 1942409156
Provider Name (Legal Business Name): CORI TAKESUE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 09/21/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SIXTH STREET
LANAI CITY HI
96763
US

IV. Provider business mailing address

PO BOX 631261
LANAI CITY HI
96763-1261
US

V. Phone/Fax

Practice location:
  • Phone: 808-565-6919
  • Fax: 808-565-9111
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-1861
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: