Provider Demographics
NPI:1306926183
Name:FREDERICK, CORY M (OTR CLT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:M
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:OTR CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E14305 CTY RD P
Mailing Address - Street 2:
Mailing Address - City:LAFARGE
Mailing Address - State:WI
Mailing Address - Zip Code:54639
Mailing Address - Country:US
Mailing Address - Phone:608-489-3353
Mailing Address - Fax:
Practice Address - Street 1:400 WATER AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634
Practice Address - Country:US
Practice Address - Phone:608-489-8260
Practice Address - Fax:608-489-8193
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1957026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40901900Medicaid
985300OtherNBCOT