Provider Demographics
NPI:1902380843
Name:FREDERICK, CHRISTINE FREDERICK MARY
Entity Type:Individual
Prefix:
First Name:CHRISTINE FREDERICK
Middle Name:MARY
Last Name:FREDERICK
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 1:55 RENEE DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:MA
Mailing Address - Zip Code:01226-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 RENEE DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:MA
Practice Address - Zip Code:01226-1038
Practice Address - Country:US
Practice Address - Phone:413-446-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA118007104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker