Provider Demographics
NPI:1578002796
Name:FREDERICK, LYDIA (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-2856
Mailing Address - Country:US
Mailing Address - Phone:517-624-2395
Mailing Address - Fax:517-668-6772
Practice Address - Street 1:4000 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917
Practice Address - Country:US
Practice Address - Phone:517-624-2395
Practice Address - Fax:517-668-6772
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst