Provider Demographics
NPI:1376730283
Name:FREDRICK, MICHELLE RAE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RAE
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 W NEELY ST
Mailing Address - Street 2:
Mailing Address - City:ATKINSON
Mailing Address - State:NE
Mailing Address - Zip Code:68713-4801
Mailing Address - Country:US
Mailing Address - Phone:402-925-2811
Mailing Address - Fax:402-925-2810
Practice Address - Street 1:406 W NEELY ST
Practice Address - Street 2:
Practice Address - City:ATKINSON
Practice Address - State:NE
Practice Address - Zip Code:68713-4801
Practice Address - Country:US
Practice Address - Phone:402-925-2811
Practice Address - Fax:402-925-2810
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist