Provider Demographics
NPI:1144488396
Name:RADKA, SALLY JO (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:RADKA
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5678GARLANDLN
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129
Mailing Address - Country:US
Mailing Address - Phone:414-427-0562
Mailing Address - Fax:
Practice Address - Street 1:5678 GARLAND LN
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1507
Practice Address - Country:US
Practice Address - Phone:414-427-0562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1519154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist