Healthcare Provider Details

I. General information

NPI: 1922932276
Provider Name (Legal Business Name): AMY MARIE FREDERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12844 COLDWATER RD STE B
FORT WAYNE IN
46845-8833
US

IV. Provider business mailing address

9823 AUBURN RD
FORT WAYNE IN
46825-2347
US

V. Phone/Fax

Practice location:
  • Phone: 260-497-7191
  • Fax:
Mailing address:
  • Phone: 260-497-7191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31007557A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: