Provider Demographics
NPI:1417957101
Name:FREDERICK, RONALD JAMES JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:JAMES
Last Name:FREDERICK
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W LAKE ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-926-8149
Mailing Address - Fax:
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:SUITE 107
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-926-8149
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4015103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical