Provider Demographics
NPI:1437976743
Name:FREDERICK, MICHAEL (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16883 YELLOWBRICK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9272
Mailing Address - Country:US
Mailing Address - Phone:541-661-3585
Mailing Address - Fax:
Practice Address - Street 1:16883 YELLOWBRICK RD
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9272
Practice Address - Country:US
Practice Address - Phone:541-661-5347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10386225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist