Provider Demographics
NPI:1407180086
Name:FREDERICK, DENISE LYNN (MS)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:LYNN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 WOODDALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2933
Mailing Address - Country:US
Mailing Address - Phone:651-738-9888
Mailing Address - Fax:
Practice Address - Street 1:2101 WOODDALE DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4441
Practice Address - Country:US
Practice Address - Phone:507-413-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103887225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist