Provider Demographics
NPI:1700190162
Name:FREDERICK, EMILY LAUREL (MA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:LAUREL
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N BALLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2533
Mailing Address - Country:US
Mailing Address - Phone:518-374-3514
Mailing Address - Fax:518-374-9193
Practice Address - Street 1:220 N BALLSTON AVE
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-2533
Practice Address - Country:US
Practice Address - Phone:518-374-3514
Practice Address - Fax:518-374-9193
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP76758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health