Provider Demographics
NPI:1508465824
Name:FREDERICK, ALEXANDER (QBHP)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3724
Mailing Address - Country:US
Mailing Address - Phone:479-705-1634
Mailing Address - Fax:479-705-1635
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3724
Practice Address - Country:US
Practice Address - Phone:479-705-1634
Practice Address - Fax:479-705-1635
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator