Provider Demographics
NPI:1184357840
Name:FREDERICK, ELIZABETH SUSAN (MA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SUSAN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5939 GRACE LEE AVE
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-8713
Mailing Address - Country:US
Mailing Address - Phone:302-542-1392
Mailing Address - Fax:
Practice Address - Street 1:10910 CLARKSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-6106
Practice Address - Country:US
Practice Address - Phone:410-313-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02529L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist