Provider Demographics
NPI:1184040479
Name:FREDERICKS, JOHN (LMT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 WESTCHESTER AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3585
Mailing Address - Country:US
Mailing Address - Phone:718-684-3050
Mailing Address - Fax:
Practice Address - Street 1:2510 WESTCHESTER AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3585
Practice Address - Country:US
Practice Address - Phone:718-684-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020375225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist