Provider Demographics
NPI:1770050536
Name:FREDERICK, COLLIN BLAKE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:BLAKE
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 HORSERANGE VISTA CT
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-2387
Mailing Address - Country:US
Mailing Address - Phone:912-294-7908
Mailing Address - Fax:
Practice Address - Street 1:3005 SARDIS RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-2232
Practice Address - Country:US
Practice Address - Phone:912-294-7908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0034322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer