Provider Demographics
NPI:1497725725
Name:FREDERICK, RICHARD IVAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:IVAN
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3423
Mailing Address - Country:US
Mailing Address - Phone:417-766-4373
Mailing Address - Fax:417-874-1633
Practice Address - Street 1:1244 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3423
Practice Address - Country:US
Practice Address - Phone:417-766-4373
Practice Address - Fax:417-874-1633
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR0334103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist