Provider Demographics
NPI:1043480668
Name:MENON, RADHIKA (PT)
Entity Type:Individual
Prefix:
First Name:RADHIKA
Middle Name:
Last Name:MENON
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 1:5350 MANHATTAN CIR
Mailing Address - Street 2:STE 100
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4272
Mailing Address - Country:US
Mailing Address - Phone:303-543-1201
Mailing Address - Fax:303-543-1206
Practice Address - Street 1:2150 STADIUM DR
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80309-0001
Practice Address - Country:US
Practice Address - Phone:303-315-9900
Practice Address - Fax:303-315-9902
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0003944225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64624722Medicaid