Provider Demographics
NPI:1912112798
Name:RADERSTORF, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RADERSTORF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7211 OHMS LN
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2148
Mailing Address - Country:US
Mailing Address - Phone:952-927-0184
Mailing Address - Fax:
Practice Address - Street 1:7211 OHMS LN
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2148
Practice Address - Country:US
Practice Address - Phone:952-927-0184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN710103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16613OtherHEALTHPARTNERS
MN6215612OtherUNITED BEHAVIORAL HEALTH