Provider Demographics
NPI:1639286065
Name:FREDERICK, PATRICIA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10735 VILLAGE CLUB CIR N
Mailing Address - Street 2:APT 105
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3038
Mailing Address - Country:US
Mailing Address - Phone:727-403-2217
Mailing Address - Fax:727-217-9779
Practice Address - Street 1:200 S HOOVER BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3540
Practice Address - Country:US
Practice Address - Phone:727-403-2217
Practice Address - Fax:727-217-9779
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 32621041C0700X
NY073584-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ5600Medicare ID - Type Unspecified