MEDICARE: MS. KATHRYN BONNEAU M.S., C.C.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA7516	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S2754	OTHER	FL	BC/BS OF FLORIDA #

General Provider Information

NPI Number	:	1043314628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHRYN BONNEAU M.S., C.C.C.

Provider Business Mailing Address
First Line	:	15210 AMBERLY DR
Second Line	:	#1531
City	:	TAMPA
State	:	FL
Zip	:	33647-2196
Country	:	US
Telephone Number	:	813-558-9006
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 VONDERBURG DR
Second Line	:	SUITE 201
City	:	BRANDON
State	:	FL
Zip	:	33511-5900
Country	:	US
Telephone Number	:	813-653-1149
Fax Number	:	813-654-6644

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	07/09/2007

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