Provider Demographics
NPI:1366724734
Name:FREDERICK, GABRIEL DAVID (LMFT, LPC)
Entity type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:DAVID
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 N MARIETTA PKWY NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1585
Mailing Address - Country:US
Mailing Address - Phone:770-919-9088
Mailing Address - Fax:
Practice Address - Street 1:698 N MARIETTA PKWY NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1585
Practice Address - Country:US
Practice Address - Phone:770-919-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001190106H00000X
GALPC006828101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional