=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619677895
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. DEBRA FREED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2023
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1637 FRANKLIN BLVD
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-309-3517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 TILTON RD # 1093
-----------------------------------------------------
City | EGG HARBOR TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08234-1831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-541-7655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------