Provider Demographics
NPI:1760762462
Name:FREDERICK, LYNN MARIE (LISW)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:MARIE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 BOTANY BAY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-3046
Mailing Address - Country:US
Mailing Address - Phone:843-297-1910
Mailing Address - Fax:
Practice Address - Street 1:421 GARDNER BLVD.
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-0100
Practice Address - Country:US
Practice Address - Phone:803-496-9000
Practice Address - Fax:803-496-9009
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical