Healthcare Provider Details

I. General information

NPI: 1679255566
Provider Name (Legal Business Name): KATELYN TAKACS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5417 WESLEYAN DR
VIRGINIA BEACH VA
23455-6922
US

IV. Provider business mailing address

5 FOSTER RD
PENNINGTON NJ
08534-5156
US

V. Phone/Fax

Practice location:
  • Phone: 757-693-4841
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202012392
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number23037
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: