Provider Demographics
NPI:1912789496
Name:PELIYAGODA, SUDARSHANA B
Entity Type:Individual
Prefix:
First Name:SUDARSHANA
Middle Name:B
Last Name:PELIYAGODA
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 1:5908 67TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-5427
Mailing Address - Country:US
Mailing Address - Phone:727-744-4377
Mailing Address - Fax:
Practice Address - Street 1:5908 67TH AVE N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5427
Practice Address - Country:US
Practice Address - Phone:727-744-4377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician