Provider Demographics
NPI:1134246226
Name:FREDERICKS, TIMOTHY G (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 HARVEY ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170
Mailing Address - Country:US
Mailing Address - Phone:734-223-4815
Mailing Address - Fax:
Practice Address - Street 1:37650 PROFESSIONAL CENTER DR SUITE 105A
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:734-953-1745
Practice Address - Fax:734-953-1743
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004832225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION95990004Medicare ID - Type Unspecified