Provider Demographics
NPI:1407493869
Name:KADAVERU, SOWMYA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SOWMYA
Middle Name:
Last Name:KADAVERU
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 W 11TH ST STE 119
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3860
Mailing Address - Country:US
Mailing Address - Phone:209-237-2484
Mailing Address - Fax:209-247-2485
Practice Address - Street 1:632 W 11TH ST STE 119
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3860
Practice Address - Country:US
Practice Address - Phone:209-247-2484
Practice Address - Fax:209-247-2485
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26684235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist