Provider Demographics
NPI:1518056852
Name:FREDERICK, PAUL E (LISW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 VESTER AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-7302
Mailing Address - Country:US
Mailing Address - Phone:937-390-3800
Mailing Address - Fax:937-390-3804
Practice Address - Street 1:1130 VESTER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-7302
Practice Address - Country:US
Practice Address - Phone:937-390-3800
Practice Address - Fax:937-390-3804
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI15771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW17071Medicare ID - Type Unspecified