Provider Demographics
NPI:1063007102
Name:FREDERICK, CASEY C (MA, LGPAT, LGPC)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:C
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MA, LGPAT, LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12652 AUBREY GLEN TER
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7826
Mailing Address - Country:US
Mailing Address - Phone:814-562-0224
Mailing Address - Fax:
Practice Address - Street 1:8 BROOKES AVE STE 200
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2799
Practice Address - Country:US
Practice Address - Phone:240-452-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATG272101YM0800X
MDLGP10570101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1861036436Medicaid