Provider Demographics
NPI:1942219043
Name:CHASE, FRED BRIAN (PHD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:BRIAN
Last Name:CHASE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-4912
Mailing Address - Country:US
Mailing Address - Phone:215-561-0202
Mailing Address - Fax:856-745-9008
Practice Address - Street 1:135 S 19TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19103-4912
Practice Address - Country:US
Practice Address - Phone:215-561-0202
Practice Address - Fax:856-745-9008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2012-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA003384103T00000X
NJ028494103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39350Medicare ID - Type Unspecified
NJ028494Medicare ID - Type Unspecified