MEDICARE: MRS. SOPHIA CARINA GRODOTZKE LCSW

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1427424860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SOPHIA CARINA GRODOTZKE LCSW

Provider Business Mailing Address
First Line	:	3828 20TH ST N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33714-4623
Country	:	US
Telephone Number	:	631-371-4524
Fax Number	:

Provider Business Practice Location Address
First Line	:	3828 20TH ST N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33714-4623
Country	:	US
Telephone Number	:	631-371-4524
Fax Number	:

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

Provider Enumeration Date	:	08/20/2015
Last Update Date	:	08/12/2024

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