Provider Demographics
NPI:1134445711
Name:RADKE, KRISTEN M (COTA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:RADKE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 9TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-4806
Mailing Address - Country:US
Mailing Address - Phone:406-488-8902
Mailing Address - Fax:
Practice Address - Street 1:2300 WILSON ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5078
Practice Address - Country:US
Practice Address - Phone:406-874-2687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT620224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant