Healthcare Provider Details

I. General information

NPI: 1659631349
Provider Name (Legal Business Name): MARTHA SUE TAKATA AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6625 LYNDALE AVE S STE 105
RICHFIELD MN
55423-2673
US

IV. Provider business mailing address

6625 LYNDALE AVE S STE 300
RICHFIELD MN
55423-2491
US

V. Phone/Fax

Practice location:
  • Phone: 612-243-8999
  • Fax: 612-869-3473
Mailing address:
  • Phone: 612-243-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number8928
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: