Provider Demographics
NPI:1487635363
Name:FREDERICK, JULIE D (PHD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:D
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9900 SW WILSHIRE ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5035
Mailing Address - Country:US
Mailing Address - Phone:503-894-9255
Mailing Address - Fax:503-385-0343
Practice Address - Street 1:9900 SW WILSHIRE ST
Practice Address - Street 2:SUITE 160
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5035
Practice Address - Country:US
Practice Address - Phone:503-894-9255
Practice Address - Fax:503-385-0343
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR1006103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR035142Medicaid