Provider Demographics
NPI:1619123551
Name:FREDENBURG, JULIE MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:MARIE
Last Name:FREDENBURG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5211
Mailing Address - Country:US
Mailing Address - Phone:573-450-9267
Mailing Address - Fax:
Practice Address - Street 1:25 N SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5211
Practice Address - Country:US
Practice Address - Phone:573-450-9267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006028757235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist