Provider Demographics
NPI:1407376437
Name:RIDDEL, ROBERTA L (PT, DPT, CCI)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:L
Last Name:RIDDEL
Suffix:
Gender:F
Credentials:PT, DPT, CCI
Other - Prefix:MISS
Other - First Name:ROBERTA
Other - Middle Name:L
Other - Last Name:PRINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:132 SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:PALISADE
Mailing Address - State:CO
Mailing Address - Zip Code:81526-9709
Mailing Address - Country:US
Mailing Address - Phone:970-639-0248
Mailing Address - Fax:
Practice Address - Street 1:321 ROOD AVE UNIT 100
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2420
Practice Address - Country:US
Practice Address - Phone:970-325-6026
Practice Address - Fax:970-325-6169
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0014977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTL.0014977OtherCO DORA
COPTL0014977OtherCO DORA