Provider Demographics
NPI:1851535009
Name:RADOSEVICH, DEIRDRE (PHD)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:RADOSEVICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3336 COTTAGE HILL DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6139
Mailing Address - Country:US
Mailing Address - Phone:740-972-1075
Mailing Address - Fax:
Practice Address - Street 1:5317 W GRANDE MARKET DR STE F7
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8465
Practice Address - Country:US
Practice Address - Phone:920-430-0736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2992-57103TC0700X
2992103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346622214Medicaid