Provider Demographics
NPI:1902361355
Name:FREDRICK, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-4546
Mailing Address - Country:US
Mailing Address - Phone:619-288-0058
Mailing Address - Fax:
Practice Address - Street 1:1133 COLLEGE AVE STE E230
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2818
Practice Address - Country:US
Practice Address - Phone:785-587-1825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-21-56631103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst