Healthcare Provider Details

I. General information

NPI: 1912336835
Provider Name (Legal Business Name): RAYMOND CABOT RADEKA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 07/05/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26001 REDLANDS BLVD # CA
REDLANDS CA
92373-7762
US

IV. Provider business mailing address

PO BOX 2388
LAKE ARROWHEAD CA
92352-2388
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII057290518
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW102529
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: