Healthcare Provider Details

I. General information

NPI: 1316591019
Provider Name (Legal Business Name): ETHAN RADATZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 S BROADWAY
LORAIN OH
44053-3821
US

IV. Provider business mailing address

292 BENEDICT AVE
NORWALK OH
44857-2374
US

V. Phone/Fax

Practice location:
  • Phone: 440-233-7232
  • Fax: 440-204-4315
Mailing address:
  • Phone: 419-663-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.170469
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: