Provider Demographics
NPI:1437260247
Name:FREDERICKS, ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 KINGSWAY CT
Mailing Address - Street 2:SUITE 201A
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1952
Mailing Address - Country:US
Mailing Address - Phone:734-692-2696
Mailing Address - Fax:
Practice Address - Street 1:1545 KINGSWAY CT
Practice Address - Street 2:SUITE 201A
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-1952
Practice Address - Country:US
Practice Address - Phone:734-692-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002524103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S92217Medicare UPIN
M89870001Medicare PIN