Provider Demographics
NPI:1831809367
Name:RADLEY, IRENE (CMT, CMLDT)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:RADLEY
Suffix:
Gender:F
Credentials:CMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 COLFAX DR
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-4419
Mailing Address - Country:US
Mailing Address - Phone:619-786-3033
Mailing Address - Fax:
Practice Address - Street 1:2204 GARNET AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3771
Practice Address - Country:US
Practice Address - Phone:619-786-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27705225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist