Provider Demographics
NPI:1609140128
Name:FREDERICKS, BRIANNE M
Entity Type:Individual
Prefix:MS
First Name:BRIANNE
Middle Name:M
Last Name:FREDERICKS
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 1:200 GRIFFIN RD STE 5
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7145
Mailing Address - Country:US
Mailing Address - Phone:800-778-5560
Mailing Address - Fax:800-778-5560
Practice Address - Street 1:200 GRIFFIN RD STE 5
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7145
Practice Address - Country:US
Practice Address - Phone:800-778-5560
Practice Address - Fax:800-778-5560
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-12655103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst