Provider Demographics
NPI:1639611783
Name:MCDONALD, FREDRICK
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 ROMA DR APT 519
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4670
Mailing Address - Country:US
Mailing Address - Phone:601-410-5505
Mailing Address - Fax:
Practice Address - Street 1:200 N THOMAS DR
Practice Address - Street 2:SUITE A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107
Practice Address - Country:US
Practice Address - Phone:318-424-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health