MEDICARE: STEPHANIE FREDEKING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2-0806-6	TX

General Provider Information

NPI Number	:	1558786327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE FREDEKING

Provider Business Mailing Address
First Line	:	1200 SUMMIT AVE
Second Line	:	SUITE 740
City	:	FORT WORTH
State	:	TX
Zip	:	76102-4403
Country	:	US
Telephone Number	:	817-292-8787
Fax Number	:	817-789-6849

Provider Business Practice Location Address
First Line	:	1200 SUMMIT AVE
Second Line	:	SUITE 740
City	:	FORT WORTH
State	:	TX
Zip	:	76102-4403
Country	:	US
Telephone Number	:	817-292-8787
Fax Number	:	817-789-6849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2014
Last Update Date	:	03/04/2014

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Directions to “ STEPHANIE FREDEKING ” Practice Location

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