Provider Demographics
NPI:1336409630
Name:DETRICK, TREDEA R
Entity Type:Individual
Prefix:MRS
First Name:TREDEA
Middle Name:R
Last Name:DETRICK
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 1:1015 JENNYS LN
Mailing Address - Street 2:
Mailing Address - City:FERNLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89408-9325
Mailing Address - Country:US
Mailing Address - Phone:775-750-1864
Mailing Address - Fax:
Practice Address - Street 1:1015 JENNYS LN
Practice Address - Street 2:
Practice Address - City:FERNLEY
Practice Address - State:NV
Practice Address - Zip Code:89408-9325
Practice Address - Country:US
Practice Address - Phone:775-750-1864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner