Provider Demographics
NPI:1275092165
Name:FREDES, ANGELICA MARIA
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIA
Last Name:FREDES
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 1:8950 56TH AVE APT 5U
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4906
Mailing Address - Country:US
Mailing Address - Phone:917-943-9289
Mailing Address - Fax:
Practice Address - Street 1:8950 56TH AVE APT 5U
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4906
Practice Address - Country:US
Practice Address - Phone:917-943-9289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician