Provider Demographics
NPI:1831985373
Name:FREDERICK, MIRRANDA
Entity type:Individual
Prefix:
First Name:MIRRANDA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BULL FROG LN
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-7758
Mailing Address - Country:US
Mailing Address - Phone:443-466-5782
Mailing Address - Fax:
Practice Address - Street 1:15 BULL FROG LN
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-7758
Practice Address - Country:US
Practice Address - Phone:443-466-5782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker