Provider Demographics
NPI:1326067331
Name:RADTKE, SUSAN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:RADTKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8581 DOLFOR CV
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8350
Mailing Address - Country:US
Mailing Address - Phone:630-323-5304
Mailing Address - Fax:630-323-5304
Practice Address - Street 1:11952 SOUTH HARLEM AVE
Practice Address - Street 2:SUITE 200 B
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1167
Practice Address - Country:US
Practice Address - Phone:708-361-5100
Practice Address - Fax:708-361-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632203OtherBLUE CROSS/BLUE SHIELD ID
IL01632203OtherBLUE CROSS/BLUE SHIELD ID