Provider Demographics
NPI:1326239229
Name:RADKE, MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:RADKE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BLATNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17280 W NORTH AVE
Mailing Address - Street 2:#104
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4366
Mailing Address - Country:US
Mailing Address - Phone:262-780-0707
Mailing Address - Fax:
Practice Address - Street 1:17280 W NORTH AVE
Practice Address - Street 2:#104
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-4366
Practice Address - Country:US
Practice Address - Phone:262-780-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist