Provider Demographics
NPI:1700412145
Name:WEATHERSPOON, FREDERICK (LCDC)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:WEATHERSPOON
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4747
Mailing Address - Country:US
Mailing Address - Phone:269-262-1815
Mailing Address - Fax:
Practice Address - Street 1:2512 N VELASCO ST STE 300
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-3180
Practice Address - Country:US
Practice Address - Phone:832-457-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33708101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)