Provider Demographics
NPI:1003169517
Name:FREDRICKSON, HOLLY (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 N CHARLES ST
Mailing Address - Street 2:APT. #2201
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3855 GREENSPRING AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-3300
Practice Address - Country:US
Practice Address - Phone:410-225-9160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06881235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDAHN811170124OtherBLUE CROSS BLUE SHIELD