Basic Information
| Provider Information | |||||||||
| NPI: | 1235396581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADTKE | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | P.T.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | N4433 COUNTY ROAD T | ||||||||
| Address2: | |||||||||
| City: | SHAWANO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541666965 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1625 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CLINTONVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549298407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158233135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 168-019 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40240300 | 05 | WI | MEDICAID |