Provider Demographics
NPI:1770824427
Name:FREDRICKSON-TATE, GAY (LSW)
Entity Type:Individual
Prefix:MS
First Name:GAY
Middle Name:
Last Name:FREDRICKSON-TATE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 NAOMI LN
Mailing Address - Street 2:
Mailing Address - City:CHALFONT
Mailing Address - State:PA
Mailing Address - Zip Code:18914-2513
Mailing Address - Country:US
Mailing Address - Phone:215-520-1639
Mailing Address - Fax:215-997-5897
Practice Address - Street 1:18 HILLTOP RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3736
Practice Address - Country:US
Practice Address - Phone:215-520-1639
Practice Address - Fax:215-997-5897
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA127737104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker