Provider Demographics
NPI:1205844263
Name:SACKS, FREDERICK MARK (PHD)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:MARK
Last Name:SACKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:FRED
Other - Middle Name:M
Other - Last Name:SACKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1485 COMMERCE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371
Mailing Address - Country:US
Mailing Address - Phone:937-667-5126
Mailing Address - Fax:937-667-7583
Practice Address - Street 1:1485 COMMERCE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:TIPP CITY
Practice Address - State:OH
Practice Address - Zip Code:45371
Practice Address - Country:US
Practice Address - Phone:937-667-5126
Practice Address - Fax:937-667-7583
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3768103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0654635Medicaid
OHSACP08991Medicare ID - Type Unspecified
OHSACP08993Medicare ID - Type Unspecified