Provider Demographics
NPI:1629558440
Name:FREDERICK, DEA (MS)
Entity Type:Individual
Prefix:
First Name:DEA
Middle Name:
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 1:50274 ANTIOCH RD
Mailing Address - Street 2:
Mailing Address - City:TICKFAW
Mailing Address - State:LA
Mailing Address - Zip Code:70466-1730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50274 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:TICKFAW
Practice Address - State:LA
Practice Address - Zip Code:70466-1730
Practice Address - Country:US
Practice Address - Phone:985-373-5448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5413235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist