Provider Demographics
NPI:1194234922
Name:TAAKE, AMY (LPC, SAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:TAAKE
Suffix:
Gender:F
Credentials:LPC, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 N LYNNDALE DR STE 2D
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-3091
Mailing Address - Country:US
Mailing Address - Phone:920-385-1420
Mailing Address - Fax:
Practice Address - Street 1:1011 N LYNNDALE DR STE 2D
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3091
Practice Address - Country:US
Practice Address - Phone:920-385-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16225-131101YA0400X
WI3679-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI813042847Medicaid