Provider Demographics
NPI:1912217837
Name:RISARD, FREDERICK WILLIAM
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:RISARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4529
Mailing Address - Country:US
Mailing Address - Phone:209-658-9832
Mailing Address - Fax:
Practice Address - Street 1:9829 BLUE LARKSPUR LN
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-6535
Practice Address - Country:US
Practice Address - Phone:209-658-9832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA797591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA76759OtherBOARD OF BEHAVIORAL SCIENCES