Provider Demographics
NPI:1720586928
Name:FREDERICK, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 EASTMAN ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2210
Mailing Address - Country:US
Mailing Address - Phone:617-831-5584
Mailing Address - Fax:
Practice Address - Street 1:33 EASTMAN ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2210
Practice Address - Country:US
Practice Address - Phone:617-831-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X, 225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty