Healthcare Provider Details

I. General information

NPI: 1689331605
Provider Name (Legal Business Name): MACY FREDERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 CEDAR ST
AURORA IL
60506-3951
US

IV. Provider business mailing address

359 CEDAR ST
AURORA IL
60506-3951
US

V. Phone/Fax

Practice location:
  • Phone: 641-638-8044
  • Fax: 331-319-3990
Mailing address:
  • Phone: 641-638-0448
  • Fax: 331-319-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146.017849
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: