Provider Demographics
NPI:1326084435
Name:KODIYAN, VARGHESE (LCSW,PA)
Entity Type:Individual
Prefix:MR
First Name:VARGHESE
Middle Name:
Last Name:KODIYAN
Suffix:
Gender:M
Credentials:LCSW,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 SHELLCRACKER CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1214
Mailing Address - Country:US
Mailing Address - Phone:813-245-7326
Mailing Address - Fax:813-964-0453
Practice Address - Street 1:1601 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4748
Practice Address - Country:US
Practice Address - Phone:813-245-7326
Practice Address - Fax:813-964-0453
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW44201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ7581Medicare ID - Type UnspecifiedLCSW