Provider Demographics
NPI:1306521778
Name:FREDERICKS, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 GANSEVOORT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12803-5735
Mailing Address - Country:US
Mailing Address - Phone:518-409-6458
Mailing Address - Fax:
Practice Address - Street 1:565 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1443
Practice Address - Country:US
Practice Address - Phone:518-321-1380
Practice Address - Fax:518-797-1599
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP121495104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker