Provider Demographics
NPI:1114087822
Name:FREDERICKS, ERIN J (SLP MSE CCCSLP)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:J
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:SLP MSE CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 KELLER AVE S
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001
Mailing Address - Country:US
Mailing Address - Phone:715-268-6900
Mailing Address - Fax:715-268-6895
Practice Address - Street 1:505 KELLER AVE S
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001
Practice Address - Country:US
Practice Address - Phone:715-268-6900
Practice Address - Fax:715-268-6895
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2700154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42581800Medicaid
4601079OtherMEDICA INS
HP69968OtherHEALTH PARTNERS
00BL1PAOtherBC BS OF MN