Basic Information
| Provider Information | |||||||||
| NPI: | 1578698346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SODRE | ||||||||
| FirstName: | DANIELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10014 N DALE MABRY HWY STE C-100 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336184426 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2565 N TOLEDO BLADE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH PORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342899306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008920640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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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 | SA12341 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 811768300 | 05 | FL | MEDICAID |