Provider Demographics
NPI:1700504594
Name:FREDRICK, MARC STANTON
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:STANTON
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 STARVIOLET ST
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1442
Mailing Address - Country:US
Mailing Address - Phone:346-305-1552
Mailing Address - Fax:
Practice Address - Street 1:22 STARVIOLET ST
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-1442
Practice Address - Country:US
Practice Address - Phone:346-305-1552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist