Healthcare Provider Details

I. General information

NPI: 1053602086
Provider Name (Legal Business Name): DEANDREA DENISE FEDRICK TVI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 S ADA ST
CHICAGO IL
60643-4428
US

IV. Provider business mailing address

11400 S ADA ST
CHICAGO IL
60643-4428
US

V. Phone/Fax

Practice location:
  • Phone: 773-954-4997
  • Fax:
Mailing address:
  • Phone: 773-954-4997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: