Provider Demographics
NPI:1073257929
Name:RADDEN, DWAINE EDWARD JR
Entity Type:Individual
Prefix:
First Name:DWAINE
Middle Name:EDWARD
Last Name:RADDEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 ALEXIAN DR STE AB
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1901
Mailing Address - Country:US
Mailing Address - Phone:408-272-6553
Mailing Address - Fax:
Practice Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1222
Practice Address - Country:US
Practice Address - Phone:650-573-3571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106145104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker