Basic Information
| Provider Information | |||||||||
| NPI: | 1245482868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4212 W CONGRESS ST | ||||||||
| Address2: | STE. 3200 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705066765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379885646 | ||||||||
| FaxNumber: | 3379884298 | ||||||||
| Practice Location | |||||||||
| Address1: | 4212 W CONGRESS ST | ||||||||
| Address2: | STE. 3200 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705066765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379885646 | ||||||||
| FaxNumber: | 3379884298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2008 | ||||||||
| LastUpdateDate: | 10/14/2008 | ||||||||
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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 | 225700000X | LA0933-01 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.