Provider Demographics
NPI:1740220474
Name:MODER, FREDERICK J (LICSW)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
Last Name:MODER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 WORCESTER ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-5420
Mailing Address - Country:US
Mailing Address - Phone:781-431-5270
Mailing Address - Fax:781-431-5535
Practice Address - Street 1:230 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-5420
Practice Address - Country:US
Practice Address - Phone:781-431-5270
Practice Address - Fax:781-431-5535
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1051911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP03399OtherBLUE CROSS
MA669500OtherTUFTS HEALTH PLAN
MA669500OtherTUFTS HEALTH PLAN