Provider Demographics
NPI:1235290438
Name:RADKE, MICHAEL R (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:RADKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 60TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4041
Mailing Address - Country:US
Mailing Address - Phone:262-654-5333
Mailing Address - Fax:262-654-7818
Practice Address - Street 1:920 60TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4041
Practice Address - Country:US
Practice Address - Phone:262-654-5333
Practice Address - Fax:262-654-7818
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI223-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
137813OtherMANAGED HEALTH NETWORK
166371OtherVALUE OPTIONS
WI39501700Medicaid
5142131OtherAETNA
79962OtherUNITED BEHAVIORAL HEALTH
W007066OtherTRICARE CHAMPUS
79962OtherUNITED BEHAVIORAL HEALTH