Provider Demographics
NPI:1619717790
Name:FRAZIER, MEDORA
Entity type:Individual
Prefix:
First Name:MEDORA
Middle Name:
Last Name:FRAZIER
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 1:4345 WOODFIELD DR
Mailing Address - Street 2:
Mailing Address - City:POMFRET
Mailing Address - State:MD
Mailing Address - Zip Code:20675-3220
Mailing Address - Country:US
Mailing Address - Phone:301-653-2314
Mailing Address - Fax:
Practice Address - Street 1:400 N COLUMBUS ST STE 201
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2264
Practice Address - Country:US
Practice Address - Phone:571-450-9145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
VA071012499101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health