Provider Demographics
NPI:1467979757
Name:RADELT, MARIA LOUISE
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:LOUISE
Last Name:RADELT
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 1:42353 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-5040
Mailing Address - Country:US
Mailing Address - Phone:810-790-2763
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-257-3705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016113103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical