MEDICARE: TAKOS PSYCHOLOGY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	21903	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285154450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAKOS PSYCHOLOGY, PC

Provider Business Mailing Address
First Line	:	901 DOVE ST STE 150
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-3018
Country	:	US
Telephone Number	:	949-701-7976
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 DOVE ST STE 150
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-3018
Country	:	US
Telephone Number	:	949-701-7976
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL PSYCHOLOGIST
Name	:	DIMITRA TAKOS
Credential	:	PSYD
Telephone Number	:	949-701-7976

Provider Enumeration Date	:	06/20/2017
Last Update Date	:	07/21/2022

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