Provider Demographics
NPI:1154183341
Name:STANLEY, FREDERICK S III
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:S
Last Name:STANLEY
Suffix:III
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 1:200 7TH AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4669
Mailing Address - Country:US
Mailing Address - Phone:831-462-1060
Mailing Address - Fax:
Practice Address - Street 1:200 7TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4669
Practice Address - Country:US
Practice Address - Phone:831-462-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-WFIUCD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist