Provider Demographics
NPI:1992034896
Name:FREDRICKSON, EUNICE DELORES (PT)
Entity Type:Individual
Prefix:MRS
First Name:EUNICE
Middle Name:DELORES
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6768 NORTH HWY 67
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034
Mailing Address - Country:US
Mailing Address - Phone:314-741-9101
Mailing Address - Fax:
Practice Address - Street 1:6768 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2742
Practice Address - Country:US
Practice Address - Phone:314-741-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009035682225100000X
IL070017473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist