Provider Demographics
NPI:1336248806
Name:RADASCH, PETER D (PSYD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:RADASCH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 WESTERN AVE APT 715
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-3304
Mailing Address - Country:US
Mailing Address - Phone:860-236-7333
Mailing Address - Fax:860-439-2087
Practice Address - Street 1:41 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1972
Practice Address - Country:US
Practice Address - Phone:860-539-0185
Practice Address - Fax:860-439-2087
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002295103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT680001516Medicare ID - Type UnspecifiedPROVIDER #