Provider Demographics
NPI:1689915308
Name:FREDA, COLETTE Y
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:Y
Last Name:FREDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 MIDDLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5543
Mailing Address - Country:US
Mailing Address - Phone:904-716-0235
Mailing Address - Fax:
Practice Address - Street 1:3680 MIDDLEBROOK DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-5543
Practice Address - Country:US
Practice Address - Phone:904-716-0235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT15674225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist