Provider Demographics
NPI:1750828646
Name:FREDERICKS, DANIEL WILLIAM
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WILLIAM
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 CENTRE ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-5197
Mailing Address - Country:US
Mailing Address - Phone:518-928-5689
Mailing Address - Fax:
Practice Address - Street 1:418 CENTRE ST UNIT C
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-5197
Practice Address - Country:US
Practice Address - Phone:518-928-5689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2316103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst