Provider Demographics
NPI:1821344151
Name:WOOLVERTON, FREDERICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
Last Name:WOOLVERTON
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 1:21 W MOUNTAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-6086
Mailing Address - Country:US
Mailing Address - Phone:917-502-0896
Mailing Address - Fax:212-253-4136
Practice Address - Street 1:21 W MOUNTAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-6086
Practice Address - Country:US
Practice Address - Phone:917-502-0896
Practice Address - Fax:212-253-4136
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04-19P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist