Provider Demographics
NPI:1154770113
Name:FEDRICK, ELIZABETH (LPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FEDRICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 S POWER RD STE 116
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-9282
Mailing Address - Country:US
Mailing Address - Phone:480-988-5003
Mailing Address - Fax:
Practice Address - Street 1:1206 E WARNER RD STE 203
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3132
Practice Address - Country:US
Practice Address - Phone:480-590-3915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-15833101YM0800X
AZLPC-17899101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health