Provider Demographics
NPI:1750977690
Name:FREDERICK, TIERRA (RBT)
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7226 CARDINAL COVE CIR # 7226
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6334
Mailing Address - Country:US
Mailing Address - Phone:954-806-2591
Mailing Address - Fax:
Practice Address - Street 1:7226 CARDINAL COVE CIR APT 7226
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6334
Practice Address - Country:US
Practice Address - Phone:954-806-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician