Provider Demographics
NPI:1497865075
Name:WILLOUGHBY, FREDERICK WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:WILLOUGHBY
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 1:1901 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7451
Mailing Address - Country:US
Mailing Address - Phone:254-743-2866
Mailing Address - Fax:254-743-0495
Practice Address - Street 1:1901 S 1ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-743-2866
Practice Address - Fax:254-743-0495
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23185103T00000X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1221571414OtherPSYCHOLOGIST