MEDICARE: MRS. SREELETHA SUSEELA AMMA KADAVIL

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1104442912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SREELETHA SUSEELA AMMA KADAVIL

Provider Business Mailing Address
First Line	:	12 N ALBERT ST
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-2551
Country	:	US
Telephone Number	:	352-484-5661
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 N ALBERT ST
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-2551
Country	:	US
Telephone Number	:	352-484-5661
Fax Number	:

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

Provider Enumeration Date	:	06/18/2020
Last Update Date	:	06/18/2020

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