Provider Demographics
NPI:1114164662
Name:FREDERICK, LAURA M (MFTI)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 SUNRISE AVENUE
Mailing Address - Street 2:SUITE D115
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4509
Mailing Address - Country:US
Mailing Address - Phone:916-772-6158
Mailing Address - Fax:
Practice Address - Street 1:720 SUNRISE AVE
Practice Address - Street 2:SUITE D115
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4516
Practice Address - Country:US
Practice Address - Phone:916-772-6158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI 55241106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist