Provider Demographics
NPI:1104197110
Name:NAYLOR, FREDERIK AUSTIN (LMSW)
Entity Type:Individual
Prefix:
First Name:FREDERIK
Middle Name:AUSTIN
Last Name:NAYLOR
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-3170
Mailing Address - Country:US
Mailing Address - Phone:269-344-0202
Mailing Address - Fax:269-344-0285
Practice Address - Street 1:1608 LAKE ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-3170
Practice Address - Country:US
Practice Address - Phone:269-344-0202
Practice Address - Fax:269-344-0285
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010888241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3402136Medicaid