Provider Demographics
NPI:1417225244
Name:FREDERICK, ISAAC JOSEPH
Entity Type:Individual
Prefix:MR
First Name:ISAAC
Middle Name:JOSEPH
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 HARBOR BLVD BLDG E
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-4018
Mailing Address - Country:US
Mailing Address - Phone:650-802-3351
Mailing Address - Fax:650-591-3043
Practice Address - Street 1:310 HARBOR BLVD BLDG E
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4018
Practice Address - Country:US
Practice Address - Phone:650-802-3351
Practice Address - Fax:650-591-3043
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOH35778101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1411033663OtherEMPLOYER ID NUMBER