Provider Demographics
NPI:1780743542
Name:RADDATZ, COURTNEY NICOLE (LMP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:RADDATZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 9TH ST SE APT 2
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-5710
Mailing Address - Country:US
Mailing Address - Phone:253-230-2919
Mailing Address - Fax:253-761-8746
Practice Address - Street 1:1919 N PEARL ST STE A4
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2456
Practice Address - Country:US
Practice Address - Phone:253-230-2919
Practice Address - Fax:253-761-8746
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00018940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0194714OtherL&I PROVIDER #