Provider Demographics
NPI:1770821647
Name:TAKESHIMA, KOJI (PHD)
Entity type:Individual
Prefix:DR
First Name:KOJI
Middle Name:
Last Name:TAKESHIMA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32933 LAKE BLUESTONE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-1212
Mailing Address - Country:US
Mailing Address - Phone:916-340-5195
Mailing Address - Fax:
Practice Address - Street 1:32933 LAKE BLUESTONE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94555-1212
Practice Address - Country:US
Practice Address - Phone:916-340-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst