Healthcare Provider Details

I. General information

NPI: 1457524126
Provider Name (Legal Business Name): RAEGAN MARIE RADENHEIMER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST 116
MIAMI FL
33125-1624
US

IV. Provider business mailing address

359 MERIDIAN AVE A201
MIAMI BEACH FL
33139-8702
US

V. Phone/Fax

Practice location:
  • Phone: 305-324-4455
  • Fax:
Mailing address:
  • Phone: 305-324-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7673
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: