MEDICARE: MRS. KIM DAUM ITDS

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	:	1386858546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM DAUM ITDS

Provider Business Mailing Address
First Line	:	197 E FLOYD AVE
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-2823
Country	:	US
Telephone Number	:	407-321-6428
Fax Number	:

Provider Business Practice Location Address
First Line	:	1836 BLAINE TER
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-1768
Country	:	US
Telephone Number	:	407-539-2336
Fax Number	:	407-644-7967

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

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/09/2007

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