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General NPI Number Information
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NPI Number | 1497312516
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Entity Type | Individual
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Provider Name | TRENTON D FEDRICK
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Gender | Male
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 05/23/2019
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Provider Practice Location Address
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Address Line | 550 S PEORIA AVE
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City | TULSA
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State | OK
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Zip | 74120-3820
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Country | US
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Telephone | 918-588-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 6500 N GLENWOOD AVE APT 103
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City | CHICAGO
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State | IL
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Zip | 60626-5154
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Country | US
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Telephone | 773-386-4833
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 14583
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License Number State | IL
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