Provider Demographics
NPI:1871665505
Name:FREDERICK, KORY LEE (PSYD, LMHC)
Entity Type:Individual
Prefix:DR
First Name:KORY
Middle Name:LEE
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PSYD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 TWANA DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-4232
Mailing Address - Country:US
Mailing Address - Phone:515-727-6434
Mailing Address - Fax:515-727-6434
Practice Address - Street 1:3811 38TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3648
Practice Address - Country:US
Practice Address - Phone:515-280-3339
Practice Address - Fax:515-280-7999
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00867101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health