Provider Demographics
NPI:1316203847
Name:RADCLIFFE, TERESA MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MARIE
Last Name:RADCLIFFE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:MARIE
Other - Last Name:KOSTUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:P.O. BOX 306
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:WI
Mailing Address - Zip Code:54616
Mailing Address - Country:US
Mailing Address - Phone:608-989-2272
Mailing Address - Fax:608-989-2272
Practice Address - Street 1:206 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616
Practice Address - Country:US
Practice Address - Phone:608-989-2272
Practice Address - Fax:608-989-2272
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10711-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist