Provider Demographics
NPI:1568848752
Name:FREDERICK, THOMAS JAMES JR (PT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:FREDERICK
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 FEATHER ROCK CIR
Mailing Address - Street 2:
Mailing Address - City:MAURICE
Mailing Address - State:LA
Mailing Address - Zip Code:70555-3365
Mailing Address - Country:US
Mailing Address - Phone:337-277-5446
Mailing Address - Fax:337-988-7720
Practice Address - Street 1:112 REPUBLIC AVE STE E
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6863
Practice Address - Country:US
Practice Address - Phone:337-988-7777
Practice Address - Fax:337-988-7720
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09059OtherLA PHYSICAL THERAPY BOARD LICENSE NUMBER