Provider Demographics
NPI:1285850768
Name:FREDERICKSON, LORI GRIMES (LOTR)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:GRIMES
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5833 MOURNING DOVE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1101
Mailing Address - Country:US
Mailing Address - Phone:225-753-8777
Mailing Address - Fax:
Practice Address - Street 1:3940 PRESCOTT RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-5143
Practice Address - Country:US
Practice Address - Phone:225-355-4461
Practice Address - Fax:225-355-4488
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10414225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1317802Medicaid