Provider Demographics
NPI:1700896453
Name:FEDERER, ALEXANDR MICHAL (PHD)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDR
Middle Name:MICHAL
Last Name:FEDERER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S. MCQUEEN ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501
Mailing Address - Country:US
Mailing Address - Phone:843-992-2149
Mailing Address - Fax:843-661-5588
Practice Address - Street 1:323 S. MCQUEEN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501
Practice Address - Country:US
Practice Address - Phone:843-992-2149
Practice Address - Fax:843-992-2149
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC569103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0173Medicaid
SCPS0173Medicaid
Q31386Medicare UPIN
Q313861186Medicare ID - Type Unspecified