Provider Demographics
NPI:1245527944
Name:FREDERICKS, LORETTA (LCSW)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 SKYHILL RD
Mailing Address - Street 2:APT. 5
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4957
Mailing Address - Country:US
Mailing Address - Phone:703-380-0035
Mailing Address - Fax:
Practice Address - Street 1:10560 MAIN ST
Practice Address - Street 2:SUITE 405
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7182
Practice Address - Country:US
Practice Address - Phone:703-380-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040076881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical