Provider Demographics
NPI:1619370855
Name:RADFORD, MARYKAY
Entity type:Individual
Prefix:
First Name:MARYKAY
Middle Name:
Last Name:RADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 S BROTON RD
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9792
Mailing Address - Country:US
Mailing Address - Phone:231-739-4359
Mailing Address - Fax:231-733-6151
Practice Address - Street 1:3285 S BROTON RD
Practice Address - Street 2:
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-9792
Practice Address - Country:US
Practice Address - Phone:231-739-4359
Practice Address - Fax:231-733-6151
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)