Provider Demographics
NPI:1467506097
Name:FEARDAY, FREDERICK L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:L
Last Name:FEARDAY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 W SAN RAFAEL ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6136
Mailing Address - Country:US
Mailing Address - Phone:813-420-6696
Mailing Address - Fax:
Practice Address - Street 1:2804 W SAN RAFAEL ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6136
Practice Address - Country:US
Practice Address - Phone:813-420-6696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW3162104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766499100Medicaid
FL763999600Medicaid