Provider Demographics
NPI:1811776701
Name:FREDERICK, DALTON (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:
Practice Address - Street 1:6300 E LAKE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-6771
Practice Address - Country:US
Practice Address - Phone:228-215-2240
Practice Address - Fax:228-215-2241
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT-4052225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist