Provider Demographics
NPI:1720804032
Name:FRIDGE WILSON, MARTHA JEAN (LBS1, ELEMENTAR ,ESL)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JEAN
Last Name:FRIDGE WILSON
Suffix:
Gender:F
Credentials:LBS1, ELEMENTAR ,ESL
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:J
Other - Last Name:FRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:642 E 49TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1554
Mailing Address - Country:US
Mailing Address - Phone:312-834-4809
Mailing Address - Fax:
Practice Address - Street 1:642 E 49TH ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-1554
Practice Address - Country:US
Practice Address - Phone:312-834-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist