Provider Demographics
NPI:1053602086
Name:FEDRICK, DEANDREA DENISE (TVI)
Entity type:Individual
Prefix:MS
First Name:DEANDREA
Middle Name:DENISE
Last Name:FEDRICK
Suffix:
Gender:F
Credentials:TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 S ADA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4428
Mailing Address - Country:US
Mailing Address - Phone:773-954-4997
Mailing Address - Fax:
Practice Address - Street 1:11400 S ADA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4428
Practice Address - Country:US
Practice Address - Phone:773-954-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency