Provider Demographics
NPI:1790828416
Name:RADICAN, CHARLES WILLIAM (MA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:RADICAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 116TH AVE NE
Mailing Address - Street 2:STE 105
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3010
Mailing Address - Country:US
Mailing Address - Phone:425-802-5134
Mailing Address - Fax:425-821-3336
Practice Address - Street 1:1601 116TH AVE NE
Practice Address - Street 2:STE 105
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3010
Practice Address - Country:US
Practice Address - Phone:425-802-5134
Practice Address - Fax:425-821-3336
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00008019101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health