Provider Demographics
NPI:1376187419
Name:DEMMONS, FREDERICKA L (CASE MANAGER)
Entity Type:Individual
Prefix:MS
First Name:FREDERICKA
Middle Name:L
Last Name:DEMMONS
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:FREDERICKA
Other - Middle Name:L
Other - Last Name:DEMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PRS
Mailing Address - Street 1:3095 KETTERING BLVD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1983
Mailing Address - Country:US
Mailing Address - Phone:937-603-8612
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
OH1376187419171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0379221Medicaid