Provider Demographics
NPI:1720896327
Name:FREDERICK, EMILY MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 HITCHING POST LN
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4913
Mailing Address - Country:US
Mailing Address - Phone:423-838-5167
Mailing Address - Fax:
Practice Address - Street 1:817 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3772
Practice Address - Country:US
Practice Address - Phone:706-736-1255
Practice Address - Fax:706-736-1258
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist