Provider Demographics
NPI:1760093678
Name:KONDRASHOV, SERGEY M
Entity Type:Individual
Prefix:DR
First Name:SERGEY
Middle Name:M
Last Name:KONDRASHOV
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:SERGUEI
Other - Middle Name:M
Other - Last Name:KONDRACHOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6548 TIMBER SHORES RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-9061
Mailing Address - Country:US
Mailing Address - Phone:337-442-3899
Mailing Address - Fax:
Practice Address - Street 1:427 BURNS AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3314
Practice Address - Country:US
Practice Address - Phone:863-679-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9514235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty