Provider Demographics
NPI:1891397766
Name:FREDERICK, AMBER KAYE
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:KAYE
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 1:1632 LINNBROOK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3133
Mailing Address - Country:US
Mailing Address - Phone:937-270-9167
Mailing Address - Fax:
Practice Address - Street 1:1632 LINNBROOK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3133
Practice Address - Country:US
Practice Address - Phone:937-270-9167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities