Provider Demographics
NPI:1033965538
Name:RADABAUGH, TIMOTHY LEWIS (MA, LLP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEWIS
Last Name:RADABAUGH
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 LUDINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-7804
Mailing Address - Country:US
Mailing Address - Phone:269-876-0228
Mailing Address - Fax:
Practice Address - Street 1:742 LUDINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-7804
Practice Address - Country:US
Practice Address - Phone:269-876-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004740103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist