Provider Demographics
NPI:1245417005
Name:FREDERICKS, TARA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6066
Mailing Address - Country:US
Mailing Address - Phone:631-471-7242
Mailing Address - Fax:
Practice Address - Street 1:939 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6066
Practice Address - Country:US
Practice Address - Phone:631-471-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72071728104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker