Provider Demographics
NPI:1215132733
Name:FREDERICK, TASHA MICHELLE (LISW-CP)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:MICHELLE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:MRS
Other - First Name:TASHA
Other - Middle Name:M
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:627 OLD TROLLEY RD STE A
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5673
Mailing Address - Country:US
Mailing Address - Phone:800-552-4357
Mailing Address - Fax:678-388-9244
Practice Address - Street 1:627 OLD TROLLEY RD STE A
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5673
Practice Address - Country:US
Practice Address - Phone:800-552-4357
Practice Address - Fax:678-388-9244
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050120301041C0700X
IL1490122821041C0700X
SC93091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1054Medicaid
SCSW1054Medicaid
SCQ352087951Medicare PIN