Provider Demographics
NPI:1609097591
Name:FREDERICK, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-2607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2130
Practice Address - Country:US
Practice Address - Phone:781-871-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor