Provider Demographics
NPI:1154555266
Name:FREDERICK, SHELBY Q (LMT, RP)
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:Q
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LMT, RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8021 FENWAY CIR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8255
Mailing Address - Country:US
Mailing Address - Phone:614-288-9251
Mailing Address - Fax:
Practice Address - Street 1:10503 BLACKLICK EASTERN RD # 12
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-7872
Practice Address - Country:US
Practice Address - Phone:614-288-9251
Practice Address - Fax:614-604-8967
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.017113225700000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist