Provider Demographics
NPI:1790901759
Name:FREDERICK, MARYANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 CANDLESTICK LN
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-3116
Mailing Address - Country:US
Mailing Address - Phone:989-832-3665
Mailing Address - Fax:989-832-3665
Practice Address - Street 1:1813 CANDLESTICK LN
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-3116
Practice Address - Country:US
Practice Address - Phone:989-832-3665
Practice Address - Fax:989-832-3665
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005947101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11694289OtherCAQH