Provider Demographics
NPI:1114225075
Name:FREDERICK, MARY MARGARET (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY MARGARET
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-2865
Mailing Address - Country:US
Mailing Address - Phone:212-741-6817
Mailing Address - Fax:
Practice Address - Street 1:653 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-2865
Practice Address - Country:US
Practice Address - Phone:212-741-6817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7961103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical