Basic Information
| Provider Information | |||||||||
| NPI: | 1245301514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDRICK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 E 9TH AVE | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038322054 | ||||||||
| FaxNumber: | 3038322054 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 E 9TH AVE | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038322054 | ||||||||
| FaxNumber: | 3038322054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 34 | CO | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 07967102 | 05 | CO | MEDICAID |