Provider Demographics
NPI:1902813926
Name:FREDRICK, BENITA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BENITA
Middle Name:
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:BENITA
Other - Middle Name:
Other - Last Name:FREDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2856 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1905
Mailing Address - Country:US
Mailing Address - Phone:516-594-2191
Mailing Address - Fax:
Practice Address - Street 1:49 CHURCH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3830
Practice Address - Country:US
Practice Address - Phone:516-623-6253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006435-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist