MEDICARE: JOANN T. RADEKE JOANN T. RADEKE

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	103TC0700X	Clinical Psychologist	30886	TX

General Provider Information

NPI Number	:	1508830027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANN T. RADEKE JOANN T. RADEKE

Provider Business Mailing Address
First Line	:	PO BOX 517
Second Line	:
City	:	KAUFMAN
State	:	TX
Zip	:	75142-0517
Country	:	US
Telephone Number	:	972-932-3941
Fax Number	:

Provider Business Practice Location Address
First Line	:	1004 S WASHINGTON ST
Second Line	:	SUITE 110
City	:	KAUFMAN
State	:	TX
Zip	:	75142-2739
Country	:	US
Telephone Number	:	972-932-3941
Fax Number	:	972-932-4941

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

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	07/08/2007

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