Provider Demographics
NPI:1316732399
Name:FREDERICK, LIBERTY
Entity type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13223 MADRONE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-8940
Mailing Address - Country:US
Mailing Address - Phone:707-303-5630
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:530-273-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-11
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program