MEDICARE: DANIELA SAMANTHA SIROTT

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	2255A2300X	Athletic Trainer	S630-1770-0736	IL

General Provider Information

NPI Number	:	1316679327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELA SAMANTHA SIROTT

Provider Business Mailing Address
First Line	:	1747 WINNETKA AVE
Second Line	:
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-3318
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 STANFORD DR
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33146-2065
Country	:	US
Telephone Number	:	305-284-2294
Fax Number	:

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

Provider Enumeration Date	:	06/28/2022
Last Update Date	:	06/28/2022

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