Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 0119003703 | VA |
NPI | 1184047342 |
---|---|
Provider Name | Mrs. Deidre Ann Fredericks |
First Address | Lynchburg, VA 24501-1443 |
Second Address | Lynchburg, VA 24501-1443 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2014 |
Last Update Date | 23/01/2014 |