Provider Demographics
NPI:1972839678
Name:FREDERICK, MICHAEL G SR (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:FREDERICK
Suffix:SR
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 CEDARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-2714
Mailing Address - Country:US
Mailing Address - Phone:504-762-9829
Mailing Address - Fax:504-367-7289
Practice Address - Street 1:1581 CAROL SUE AVE
Practice Address - Street 2:SUITE212
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-5100
Practice Address - Country:US
Practice Address - Phone:504-762-9829
Practice Address - Fax:504-267-7289
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical