Provider Demographics
NPI:1922613686
Name:RADTKE, PAUL (PLMHP, PLDAC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:RADTKE
Suffix:
Gender:M
Credentials:PLMHP, PLDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 N PLATTE AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2630
Mailing Address - Country:US
Mailing Address - Phone:402-753-6440
Mailing Address - Fax:
Practice Address - Street 1:2170 N PLATTE AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2630
Practice Address - Country:US
Practice Address - Phone:402-753-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health