Provider Demographics
NPI:1164584314
Name:RADACK, JULIE (PT)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:RADACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1708
Mailing Address - Country:US
Mailing Address - Phone:434-845-8765
Mailing Address - Fax:434-845-8467
Practice Address - Street 1:1912 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1708
Practice Address - Country:US
Practice Address - Phone:434-845-8765
Practice Address - Fax:434-845-8467
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211768225100000X
AZ73742251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ146624Medicaid