Provider Demographics
NPI:1366075095
Name:FREDERICK, KATIE ELIZABETH
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ELIZABETH
Last Name:FREDERICK
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 1:6848 WHEATLAND RD N APT A
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4358
Mailing Address - Country:US
Mailing Address - Phone:503-917-8831
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1188
Practice Address - Country:US
Practice Address - Phone:503-917-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst