Provider Demographics
NPI:1700439643
Name:FRIEDERICK, ELLEN LOUISE
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LOUISE
Last Name:FRIEDERICK
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 1:604 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:WI
Mailing Address - Zip Code:53510-9738
Mailing Address - Country:US
Mailing Address - Phone:608-723-9113
Mailing Address - Fax:
Practice Address - Street 1:1400 EASTSIDE RD
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-9800
Practice Address - Country:US
Practice Address - Phone:608-348-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4863-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist