Provider Demographics
NPI:1376789693
Name:FREDERICK, DITINA JADE (LMT, CHT, RM)
Entity Type:Individual
Prefix:
First Name:DITINA
Middle Name:JADE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LMT, CHT, RM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6730 E MCDOWELL RD STE 139
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-3135
Mailing Address - Country:US
Mailing Address - Phone:602-931-7817
Mailing Address - Fax:
Practice Address - Street 1:6730 E MCDOWELL RD STE 139
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3135
Practice Address - Country:US
Practice Address - Phone:602-931-7817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-07881174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist