MEDICARE: DOUGLAS RADTKE LMT, BCTMB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	405300000X	Prevention Professional	4994-146	WI

General Provider Information

NPI Number	:	1407396013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS RADTKE LMT, BCTMB

Provider Business Mailing Address
First Line	:	6233 BANKERS RD
Second Line	:	SITTE 12
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-358-6730
Fax Number	:

Provider Business Practice Location Address
First Line	:	6233 BANKERS RD
Second Line	:	SUITE 12
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53403-9700
Country	:	US
Telephone Number	:	262-358-6730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2017
Last Update Date	:	03/01/2017

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