Provider Demographics
NPI:1740396886
Name:LIST, FREDERICK P (PHD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:P
Last Name:LIST
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A200
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-5115
Practice Address - Fax:864-454-5146
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1086103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1305NOtherBLUE CROSS/BLUE SHIELD
NC60-00266Medicaid
NC60-00266Medicaid
SCQ348547951Medicare PIN