Provider Demographics
NPI:1366866311
Name:FREDERICKS, MELINDA D
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:D
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:FREDERICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CI06930217
Mailing Address - Street 1:14320 PALM DR
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-6874
Mailing Address - Country:US
Mailing Address - Phone:760-770-2264
Mailing Address - Fax:
Practice Address - Street 1:14320 PALM DR
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-6874
Practice Address - Country:US
Practice Address - Phone:760-770-2264
Practice Address - Fax:951-791-3353
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI06930217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)