Provider Demographics
NPI:1659323954
Name:FREDERICK, WILLARD J (LCSW)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:J
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:J
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3645 N BRIARWOOD LN
Mailing Address - Street 2:STE A
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5337
Mailing Address - Country:US
Mailing Address - Phone:765-289-5520
Mailing Address - Fax:
Practice Address - Street 1:240 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3988
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:765-741-0340
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001033A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN209610OMedicare ID - Type Unspecified