Provider Demographics
NPI:1780070664
Name:FRY, DANIEL OLIVER (BA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:OLIVER
Last Name:FRY
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 COMER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8725
Mailing Address - Country:US
Mailing Address - Phone:706-596-5737
Mailing Address - Fax:
Practice Address - Street 1:700 10TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2851
Practice Address - Country:US
Practice Address - Phone:706-653-4258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1441103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling