Healthcare Provider Details

I. General information

NPI: 1184047342
Provider Name (Legal Business Name): DEIDRE ANN FREDERICKS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 01/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2081 LANGHORNE RD
LYNCHBURG VA
24501-1443
US

IV. Provider business mailing address

2081 LANGHORNE RD
LYNCHBURG VA
24501-1443
US

V. Phone/Fax

Practice location:
  • Phone: 434-846-8437
  • Fax: 434-846-4032
Mailing address:
  • Phone: 434-846-8437
  • Fax: 434-846-4032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number0119003703
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: