Provider Demographics
NPI:1811633985
Name:PALMER, FREDERICK
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:PALMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16101 WHITE RIVER BLVD APT 24203
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-0009
Mailing Address - Country:US
Mailing Address - Phone:312-307-3426
Mailing Address - Fax:
Practice Address - Street 1:16101 WHITE RIVER BLVD APT 24203
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-0009
Practice Address - Country:US
Practice Address - Phone:312-307-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247200000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
8302OtherNONE
TX8308OtherNONE