Provider Demographics
NPI:1023874492
Name:FREDERICKS, TYESHIA
Entity type:Individual
Prefix:
First Name:TYESHIA
Middle Name:
Last Name:FREDERICKS
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 1:1385 HWY 35 # 284
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11954 S KILDARE AVE APT 1E
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-2325
Practice Address - Country:US
Practice Address - Phone:773-960-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician