Provider Demographics
NPI:1710522453
Name:FREDERICK, CELINA RAQUEL (RDN, LD)
Entity Type:Individual
Prefix:
First Name:CELINA
Middle Name:RAQUEL
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:CELINA
Other - Middle Name:RAQUEL
Other - Last Name:VIDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:3760 WYNDHAM RIDGE DR APT 103
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-6150
Mailing Address - Country:US
Mailing Address - Phone:330-550-1120
Mailing Address - Fax:
Practice Address - Street 1:3401 ENTERPRISE PKWY
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7341
Practice Address - Country:US
Practice Address - Phone:216-765-0500
Practice Address - Fax:216-765-0521
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08955OtherLICENSED DIETITIAN
86117372OtherREGISTERED DIETITIAN