Provider Demographics
NPI:1669531786
Name:RADTKE, MARY ALICE (MED LPC LMFT NCC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:RADTKE
Suffix:
Gender:F
Credentials:MED LPC LMFT NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 W PARK BLVD # 400
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-2586
Mailing Address - Country:US
Mailing Address - Phone:972-824-6177
Mailing Address - Fax:
Practice Address - Street 1:5055 W PARK BLVD # 400
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093
Practice Address - Country:US
Practice Address - Phone:972-824-6177
Practice Address - Fax:972-380-2006
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5057106H00000X
TX48315101Y00000X
TX14987101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor