Provider Demographics
NPI:1841675584
Name:WORTHEM, FREDRICK (TLLP)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:WORTHEM
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28475 GREENFIELD RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3034
Mailing Address - Country:US
Mailing Address - Phone:248-424-9778
Mailing Address - Fax:
Practice Address - Street 1:28475 GREENFIELD RD
Practice Address - Street 2:SUITE 207
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3034
Practice Address - Country:US
Practice Address - Phone:248-424-9778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016011103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical