Provider Demographics
NPI:1679938724
Name:RADTKE, AMANDA RAE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:RADTKE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:RAE
Other - Last Name:OSTBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:40 11TH ST
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1817
Practice Address - Country:US
Practice Address - Phone:218-879-4559
Practice Address - Fax:218-879-0282
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical