Provider Demographics
NPI:1083031736
Name:RADKE, WHITNEY (COTA/L)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:RADKE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 N 5TH AVE APT 614
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-1822
Mailing Address - Country:US
Mailing Address - Phone:785-416-0205
Mailing Address - Fax:
Practice Address - Street 1:4310 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2607
Practice Address - Country:US
Practice Address - Phone:502-704-6734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5732224Z00000X
KS18-00939224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant