Provider Demographics
NPI:1124163449
Name:FREDERICK, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 S MADISON ST
Mailing Address - Street 2:SUITE 329
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-3011
Mailing Address - Country:US
Mailing Address - Phone:303-329-3210
Mailing Address - Fax:303-329-0296
Practice Address - Street 1:155 S MADISON ST
Practice Address - Street 2:SUITE 329
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3011
Practice Address - Country:US
Practice Address - Phone:303-329-3210
Practice Address - Fax:303-329-0296
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO263552084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry