Provider Demographics
NPI:1780048546
Name:FREDERICK, DECEMBER
Entity type:Individual
Prefix:MS
First Name:DECEMBER
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DECEMBER
Other - Middle Name:
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SLPA
Mailing Address - Street 1:4528 NEWCASTLE DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-8403
Mailing Address - Country:US
Mailing Address - Phone:817-680-1388
Mailing Address - Fax:
Practice Address - Street 1:12770 COIT RD STE 870
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-1455
Practice Address - Country:US
Practice Address - Phone:972-756-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX354132355S0801X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst