Provider Demographics
NPI:1396947602
Name:RADAK, COLLEEN SUE (PTA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:SUE
Last Name:RADAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 BRAMBLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44147-2012
Mailing Address - Country:US
Mailing Address - Phone:440-838-5641
Mailing Address - Fax:
Practice Address - Street 1:4511 ROCKSIDE RD
Practice Address - Street 2:SUITE 330
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2199
Practice Address - Country:US
Practice Address - Phone:216-901-0401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH559225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant