Provider Demographics
NPI:1558391755
Name:DESIKAN, RADHIKA (OT)
Entity Type:Individual
Prefix:
First Name:RADHIKA
Middle Name:
Last Name:DESIKAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:RADHIKA
Other - Middle Name:
Other - Last Name:SRINIZASAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:20180 W 12 MILE RD
Mailing Address - Street 2:STE 4
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20180 W 12 MILE RD
Practice Address - Street 2:STE 4
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-5412
Practice Address - Country:US
Practice Address - Phone:248-799-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002935225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist