Provider Demographics
NPI:1841406188
Name:FREDERICK, KENNETH L (LMFT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3868 NE 169TH ST APT 303
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3210
Mailing Address - Country:US
Mailing Address - Phone:954-958-0988
Mailing Address - Fax:954-958-3527
Practice Address - Street 1:1925 S PERIMETER RD
Practice Address - Street 2:SUITE 120
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-7122
Practice Address - Country:US
Practice Address - Phone:954-958-0988
Practice Address - Fax:954-958-3527
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1560106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist