Provider Demographics
NPI:1134285125
Name:MCDERMOTT, FREDERICK KIRK (MA, LPC, MHSP)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:KIRK
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:MA, LPC, MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:WHITWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37397-0493
Mailing Address - Country:US
Mailing Address - Phone:423-421-8350
Mailing Address - Fax:
Practice Address - Street 1:13810 HWY 28
Practice Address - Street 2:SUITE B
Practice Address - City:WHITWELL
Practice Address - State:TN
Practice Address - Zip Code:37397
Practice Address - Country:US
Practice Address - Phone:423-421-8350
Practice Address - Fax:423-658-7180
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000001984101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441168Medicaid