Provider Demographics
NPI:1164628301
Name:FREDERICK, CAROL ANN
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
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 1:11 ROSEDALE RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2929
Mailing Address - Country:US
Mailing Address - Phone:860-916-3695
Mailing Address - Fax:
Practice Address - Street 1:91 NORTHWEST DRIVE
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062
Practice Address - Country:US
Practice Address - Phone:860-916-3695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health