Provider Demographics
NPI:1336177138
Name:FREDERICK, ERIC J (AUD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10350 N VANCOUVER WAY
Mailing Address - Street 2:#236
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7530
Mailing Address - Country:US
Mailing Address - Phone:503-928-4327
Mailing Address - Fax:503-719-8209
Practice Address - Street 1:825 NE 20TH AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2275
Practice Address - Country:US
Practice Address - Phone:503-928-4327
Practice Address - Fax:503-719-8209
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21685231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336177138OtherNPI
OR084413Medicaid
OR160046Medicare PIN