Provider Demographics
NPI:1083776942
Name:FREDERICKSON, DEBORAH LEE (SLP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:LEE
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 W HEATHERBRAE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3010
Mailing Address - Country:US
Mailing Address - Phone:602-253-1337
Mailing Address - Fax:
Practice Address - Street 1:1025 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3307
Practice Address - Country:US
Practice Address - Phone:480-472-0727
Practice Address - Fax:480-472-0705
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSPL0992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ582785Medicaid