Provider Demographics
NPI:1174921290
Name:RADTKE, DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:RADTKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11240 N FLAT GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-4608
Mailing Address - Country:US
Mailing Address - Phone:520-248-9516
Mailing Address - Fax:
Practice Address - Street 1:11240 N FLAT GRANITE DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85737-4608
Practice Address - Country:US
Practice Address - Phone:520-248-9516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-06
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-115351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical