Healthcare Provider Details

I. General information

NPI: 1629558440
Provider Name (Legal Business Name): DEA FREDERICK M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50274 ANTIOCH RD
TICKFAW LA
70466-1730
US

IV. Provider business mailing address

50274 ANTIOCH RD
TICKFAW LA
70466-1730
US

V. Phone/Fax

Practice location:
  • Phone: 985-373-5448
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5413
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: