=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801138441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MINDY ANN FREDERICK DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2013
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 851 NW 45TH ST
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64116-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-718-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9603 E 79TH TER
-----------------------------------------------------
City | RAYTOWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64138-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-718-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2009029858
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------