Provider Demographics
NPI:1811421068
Name:FREDERICK, STACEY ANNE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANNE
Last Name:FREDERICK
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 1:1 CHILDRENS WAY
Mailing Address - Street 2:SLOT 512-39
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-526-8700
Mailing Address - Fax:501-526-8740
Practice Address - Street 1:6601 PHOENIX AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5092
Practice Address - Country:US
Practice Address - Phone:479-785-9091
Practice Address - Fax:479-782-3415
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist