Provider Demographics
NPI:1679291538
Name:DEDOLPH, FREDERICK MICHAEL (LMT)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:MICHAEL
Last Name:DEDOLPH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 SUFFIELD CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2775
Mailing Address - Country:US
Mailing Address - Phone:412-477-7163
Mailing Address - Fax:
Practice Address - Street 1:5615 SUFFIELD CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2775
Practice Address - Country:US
Practice Address - Phone:412-477-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG002338225700000X
MDM05957225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist