Provider Demographics
NPI:1629151295
Name:NOLEN, FREDERICK WALLACE (PHD)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:WALLACE
Last Name:NOLEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7995 E CO RD 350 N
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47108
Mailing Address - Country:US
Mailing Address - Phone:913-907-5997
Mailing Address - Fax:
Practice Address - Street 1:31890 COLD SPRING AVE
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355-4877
Practice Address - Country:US
Practice Address - Phone:913-907-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042593A103T00000X
MO000776103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493458632Medicaid