Provider Demographics
NPI:1912336835
Name:RADEKA, RAYMOND CABOT
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:CABOT
Last Name:RADEKA
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:PO BOX 2388
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-2388
Mailing Address - Country:US
Mailing Address - Phone:909-522-2917
Mailing Address - Fax:
Practice Address - Street 1:14677 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-4219
Practice Address - Country:US
Practice Address - Phone:951-643-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAASW102529101YM0800X
CAACSW102529104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health