Provider Demographics
NPI:1336315589
Name:RADOVICH, KATHY JEANNE (OTR)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:JEANNE
Last Name:RADOVICH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 S 75TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-1255
Mailing Address - Country:US
Mailing Address - Phone:414-321-8860
Mailing Address - Fax:
Practice Address - Street 1:1948 S 75TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-1255
Practice Address - Country:US
Practice Address - Phone:414-321-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1210-026172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40555700Medicaid