Provider Demographics
NPI:1245633106
Name:FREDRICK, BEVERLY
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:FREDRICK
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:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-0225
Mailing Address - Country:US
Mailing Address - Phone:563-380-9242
Mailing Address - Fax:
Practice Address - Street 1:101 S CHARLES ST
Practice Address - Street 2:
Practice Address - City:CALMAR
Practice Address - State:IA
Practice Address - Zip Code:52132-7858
Practice Address - Country:US
Practice Address - Phone:563-380-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAX000705575Medicaid