Provider Demographics
NPI:1942819081
Name:RADONSKI, MICHAEL SYLVESTER
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SYLVESTER
Last Name:RADONSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 NW 72ND ST STE 260M
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5931
Mailing Address - Country:US
Mailing Address - Phone:405-676-1072
Mailing Address - Fax:
Practice Address - Street 1:5601 NW 72ND ST STE 260M
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5931
Practice Address - Country:US
Practice Address - Phone:405-676-1072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-16148101YM0800X
OK7311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty