Basic Information
| Provider Information | |||||||||
| NPI: | 1285858340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEDESCO | ||||||||
| FirstName: | ANNA | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 91003 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338041003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639448788 | ||||||||
| FaxNumber: | 8632980299 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 AVENUE B SE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338803037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632941429 | ||||||||
| FaxNumber: | 8632980299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA 9472 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 8923884 | 05 | FL | MEDICAID |