Provider Demographics
NPI:1407396013
Name:RADTKE, DOUGLAS (LMT, BCTMB)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:RADTKE
Suffix:
Gender:M
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6233 BANKERS RD
Mailing Address - Street 2:SITTE 12
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-9700
Mailing Address - Country:US
Mailing Address - Phone:262-358-6730
Mailing Address - Fax:
Practice Address - Street 1:6233 BANKERS RD
Practice Address - Street 2:SUITE 12
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53403-9700
Practice Address - Country:US
Practice Address - Phone:262-358-6730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4994-146405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional