Provider Demographics
NPI:1245781731
Name:FREDERICK, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FREDERICK
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 1:1701 N MAPLE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-6806
Mailing Address - Country:US
Mailing Address - Phone:605-882-6390
Mailing Address - Fax:605-882-6391
Practice Address - Street 1:1701 N MAPLE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-6806
Practice Address - Country:US
Practice Address - Phone:605-882-6390
Practice Address - Fax:605-882-6391
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD662-PROV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist