Provider Demographics
NPI:1609249762
Name:FREDRICKS, ANGELA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FREDRICKS
Suffix:
Gender:
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11954 NARCOOSSEE RD # 268
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-6998
Mailing Address - Country:US
Mailing Address - Phone:321-340-2470
Mailing Address - Fax:321-333-5682
Practice Address - Street 1:11954 NARCOOSSEE RD # 268
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-6998
Practice Address - Country:US
Practice Address - Phone:321-340-2470
Practice Address - Fax:321-333-5682
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty