Provider Demographics
NPI:1306982178
Name:FREDERICK, CARRIE E (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:E
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:E
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1619 HARDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1826
Mailing Address - Country:US
Mailing Address - Phone:863-808-1790
Mailing Address - Fax:
Practice Address - Street 1:1619 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1826
Practice Address - Country:US
Practice Address - Phone:863-808-1970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7712235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist