Provider Demographics
NPI:1245696749
Name:RADTKE, JUDITH (LICSW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:RADTKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PERKINS ST APT 125
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4333
Mailing Address - Country:US
Mailing Address - Phone:617-522-0554
Mailing Address - Fax:
Practice Address - Street 1:111 PERKINS ST APT 125
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4333
Practice Address - Country:US
Practice Address - Phone:617-522-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA100757104100000X, 1041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker