Doctor Name: | DAVID E FREDERICK |
NPI Number: | 1215035662 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | CADC III, CCSII, IDP |
License Number: | 2097 |
Business Practice Address: | 230 Park St Wautoma, WI - 549829031 |
Business Phone Number: | 9207876550 |
Business Fax Number: | 9207870421 |
Mailing Address: | 230 Park St, Po Box 1230 WAUTOMA |
State: | WI |
Postal Code: | 549829031 |
Phone Number: | 9207876550 |
Fax Number: | 9207870421 |
NPI Enumeration Date: | 09/20/2006 |
NPI Last Update Date: | 07/09/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YA0400X |
License Number: | 2097 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |