Provider Demographics
NPI:1477229201
Name:FREDERICKS, SHELBY D
Entity Type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:D
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16108 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-6542
Mailing Address - Country:US
Mailing Address - Phone:815-685-7627
Mailing Address - Fax:
Practice Address - Street 1:16108 WEBER RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-6542
Practice Address - Country:US
Practice Address - Phone:815-685-7627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0225841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical