Provider Demographics
NPI:1629363981
Name:FREDERICK, MAIR OLMSTED (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MAIR
Middle Name:OLMSTED
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 N WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-1611
Mailing Address - Country:US
Mailing Address - Phone:716-655-4325
Mailing Address - Fax:
Practice Address - Street 1:1397 ORCHARD PARK RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-4029
Practice Address - Country:US
Practice Address - Phone:716-677-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007022-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist