Provider Demographics
NPI:1003459389
Name:STREETS, FREDERICK
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:STREETS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 NICHOLS AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-3925
Mailing Address - Country:US
Mailing Address - Phone:203-296-2430
Mailing Address - Fax:
Practice Address - Street 1:602 NICHOLS AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-3925
Practice Address - Country:US
Practice Address - Phone:203-296-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-19
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002270101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty