Healthcare Provider Details

I. General information

NPI: 1407014731
Provider Name (Legal Business Name): FREDERICK HENRY MS CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3237 S 16TH ST
MILWAUKEE WI
53215-4526
US

IV. Provider business mailing address

3237 S 16TH ST
MILWAUKEE WI
53215-4526
US

V. Phone/Fax

Practice location:
  • Phone: 414-647-7422
  • Fax: 414-647-5669
Mailing address:
  • Phone: 414-647-7422
  • Fax: 414-647-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number851-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: