Provider Demographics
NPI:1245685064
Name:FREDERICK, ANN MARIE DECKER (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE DECKER
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 GREENWAY BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4358
Mailing Address - Country:US
Mailing Address - Phone:770-812-3530
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR STE 103B
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3201
Practice Address - Country:US
Practice Address - Phone:770-812-3530
Practice Address - Fax:770-812-3531
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA908772084P0800X, 2084P0804X
TN631572084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ068722Medicaid