Provider Demographics
NPI:1376813022
Name:FREDERICK, RESA (MED, NCC, LPC)
Entity Type:Individual
Prefix:MISS
First Name:RESA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MED, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 OAK GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-8469
Mailing Address - Country:US
Mailing Address - Phone:662-687-5994
Mailing Address - Fax:
Practice Address - Street 1:720 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-8469
Practice Address - Country:US
Practice Address - Phone:662-687-5994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MS2052101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health