Provider Demographics
NPI:1477917748
Name:FREDERICK, MALLORY LOGAN (BS, CDCA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LOGAN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:BS, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6434 E MAIN ST
Mailing Address - Street 2:201
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7300
Mailing Address - Country:US
Mailing Address - Phone:614-762-2847
Mailing Address - Fax:
Practice Address - Street 1:6434 E MAIN ST
Practice Address - Street 2:201
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068
Practice Address - Country:US
Practice Address - Phone:614-762-2847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150835101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)