Provider Demographics
NPI:1154644037
Name:FREDERICK, SHAWN (MS)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 WASHINGTON ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-6790
Mailing Address - Country:US
Mailing Address - Phone:812-799-1350
Mailing Address - Fax:
Practice Address - Street 1:424 WASHINGTON ST
Practice Address - Street 2:SUITE 7
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6790
Practice Address - Country:US
Practice Address - Phone:812-799-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100083280AMedicaid