Provider Demographics
NPI:1548402274
Name:SUNDARRAO, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:SUNDARRAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13139 W LINEBAUGH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4498
Mailing Address - Country:US
Mailing Address - Phone:813-932-3013
Mailing Address - Fax:813-932-3016
Practice Address - Street 1:13139 W LINEBAUGH AVE STE 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4498
Practice Address - Country:US
Practice Address - Phone:813-932-3013
Practice Address - Fax:813-932-3016
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-26
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI15502355S0801X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant