Basic Information
| Provider Information | |||||||||
| NPI: | 1205477072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FODOR | ||||||||
| FirstName: | CALLI | ||||||||
| MiddleName: | KEENAN | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10002 PRINCESS PALM AVE STE 332 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336198327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135717184 | ||||||||
| FaxNumber: | 8136544695 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 2ND AVE SW | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337703120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273410551 | ||||||||
| FaxNumber: | 7273410332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2019 | ||||||||
| LastUpdateDate: | 10/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY2309 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.