MEDICARE: AUTISM AWARENESS SHOP

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	251C00000X	Developmentally Disabled Services Day Training Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316607849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTISM AWARENESS SHOP

Provider Business Mailing Address
First Line	:	2908 W HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6055
Country	:	US
Telephone Number	:	813-879-6770
Fax Number	:

Provider Business Practice Location Address
First Line	:	2908 W HILLSBOROUGH AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-6055
Country	:	US
Telephone Number	:	813-879-6770
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. TYLER RUSSO
Credential	:
Telephone Number	:	631-413-1616

Provider Enumeration Date	:	12/24/2021
Last Update Date	:	07/06/2022

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Directions to “AUTISM AWARENESS SHOP ” Practice Location

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