Provider Demographics
NPI:1962636654
Name:FREDERICK, KEVEN
Entity Type:Individual
Prefix:
First Name:KEVEN
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 SMALLWOOD RD
Mailing Address - Street 2:APT. 69
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-3232
Mailing Address - Country:US
Mailing Address - Phone:803-209-3096
Mailing Address - Fax:
Practice Address - Street 1:4824 SMALLWOOD RD
Practice Address - Street 2:APT. 69
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-3232
Practice Address - Country:US
Practice Address - Phone:803-209-3096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3464225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist