Healthcare Provider Details

I. General information

NPI: 1497246623
Provider Name (Legal Business Name): KARYN COPPOCK TAKKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 W CENTER ST
OREM UT
84057-5104
US

IV. Provider business mailing address

758 W 2100 N
PROVO UT
84604-1240
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-2968
  • Fax:
Mailing address:
  • Phone: 801-918-9053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: