Provider Demographics
NPI:1407631948
Name:RADKA, LAUREN ELIZABETH
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:RADKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11966 WILLISTON RD
Mailing Address - Street 2:
Mailing Address - City:MARILLA
Mailing Address - State:NY
Mailing Address - Zip Code:14102-9719
Mailing Address - Country:US
Mailing Address - Phone:716-698-4570
Mailing Address - Fax:
Practice Address - Street 1:185 OLD MILITARY RD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-1939
Practice Address - Country:US
Practice Address - Phone:518-523-2464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist