MEDICARE: GRACE SUNDARRAO

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	2355S0801X	Speech-Language Assistant	SI1550	FL
2	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1548402274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE SUNDARRAO

Provider Business Mailing Address
First Line	:	13139 W LINEBAUGH AVE STE 201
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-4498
Country	:	US
Telephone Number	:	813-932-3013
Fax Number	:	813-932-3016

Provider Business Practice Location Address
First Line	:	13139 W LINEBAUGH AVE STE 201
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-4498
Country	:	US
Telephone Number	:	813-932-3013
Fax Number	:	813-932-3016

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

Provider Enumeration Date	:	03/26/2009
Last Update Date	:	07/21/2009

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Directions to “ GRACE SUNDARRAO ” Practice Location

Language	Start Address	Practice Location

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