Provider Demographics
NPI:1245893106
Name:FREDERICK, TEARA
Entity type:Individual
Prefix:
First Name:TEARA
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 1:1200 FLORAL SPRINGS BLVD UNIT 27302
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6844
Mailing Address - Country:US
Mailing Address - Phone:386-569-1618
Mailing Address - Fax:
Practice Address - Street 1:201 PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2345
Practice Address - Country:US
Practice Address - Phone:407-530-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29215225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA29215OtherPTA29215