Provider Demographics
NPI:1033143219
Name:FRAKER, TEDDY RAY (LCSW-C, PHD)
Entity Type:Individual
Prefix:DR
First Name:TEDDY
Middle Name:RAY
Last Name:FRAKER
Suffix:
Gender:M
Credentials:LCSW-C, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 EDITH STONE DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-1170
Mailing Address - Country:US
Mailing Address - Phone:410-569-8224
Mailing Address - Fax:443-625-1520
Practice Address - Street 1:135 N PARKE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-2428
Practice Address - Country:US
Practice Address - Phone:443-625-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD003071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCO32867YMedicare ID - Type Unspecified