Provider Demographics
NPI:1114131422
Name:FREDERICK, MELYSSA J
Entity Type:Individual
Prefix:MRS
First Name:MELYSSA
Middle Name:J
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 BENBOW CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2541
Mailing Address - Country:US
Mailing Address - Phone:636-207-7878
Mailing Address - Fax:636-207-7869
Practice Address - Street 1:396 BENBOW CT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2541
Practice Address - Country:US
Practice Address - Phone:636-207-7878
Practice Address - Fax:636-207-7869
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0059681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical