Provider Demographics
NPI:1568004752
Name:FREDERICK, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 MONTANA AVE STE GANDH
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-2155
Mailing Address - Country:US
Mailing Address - Phone:915-838-7604
Mailing Address - Fax:866-218-8230
Practice Address - Street 1:6601 MONTANA AVE STE GANDH
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-2155
Practice Address - Country:US
Practice Address - Phone:915-838-7604
Practice Address - Fax:866-218-8230
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX360042355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant