Provider Demographics
NPI:1588705644
Name:FREDERICK, ROAN K (MS,CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:ROAN
Middle Name:K
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 MIDLANE CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2051
Mailing Address - Country:US
Mailing Address - Phone:334-265-2054
Mailing Address - Fax:
Practice Address - Street 1:1413 MIDLANE CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2051
Practice Address - Country:US
Practice Address - Phone:334-265-2054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL315235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist