Provider Demographics
NPI:1184646432
Name:FREDERICK, MATTHEW RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 CLUB MANOR DR STE J
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7417
Mailing Address - Country:US
Mailing Address - Phone:501-687-0488
Mailing Address - Fax:501-687-0489
Practice Address - Street 1:2001 CLUB MANOR DR STE J
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7417
Practice Address - Country:US
Practice Address - Phone:501-687-0488
Practice Address - Fax:501-687-0489
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1475-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5Y095Medicare ID - Type UnspecifiedMEDICARE