Provider Demographics
NPI:1801041850
Name:RADKE, KRIS GEORGE (MC, MAT)
Entity Type:Individual
Prefix:MR
First Name:KRIS
Middle Name:GEORGE
Last Name:RADKE
Suffix:
Gender:M
Credentials:MC, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6913 W MONONA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8983
Mailing Address - Country:US
Mailing Address - Phone:623-261-8558
Mailing Address - Fax:
Practice Address - Street 1:1510 E FLOWER ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5656
Practice Address - Country:US
Practice Address - Phone:602-530-6970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0186101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPC-0186OtherLICENSE FOR PROFESSIONAL COUNSELOR