Provider Demographics
NPI:1952370777
Name:FREDERIC, KRISTA R (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:R
Last Name:FREDERIC
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-0356
Mailing Address - Country:US
Mailing Address - Phone:301-421-1125
Mailing Address - Fax:301-421-1077
Practice Address - Street 1:3909 NATIONAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-1191
Practice Address - Country:US
Practice Address - Phone:301-421-1125
Practice Address - Fax:301-421-1077
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist