Provider Demographics
NPI:1679536734
Name:WORTHY, FREDRICK EARL (ATC/L)
Entity type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:EARL
Last Name:WORTHY
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 STILLWAY DR
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-2902
Mailing Address - Country:US
Mailing Address - Phone:601-503-0824
Mailing Address - Fax:601-928-6874
Practice Address - Street 1:400 BORDER AVE E
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2822
Practice Address - Country:US
Practice Address - Phone:601-928-5492
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT01522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer