Provider Demographics
NPI:1386145332
Name:FREDERICK, KEVIN SCOTT (LPC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 TESNATEE LANDING DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-3874
Mailing Address - Country:US
Mailing Address - Phone:912-278-2729
Mailing Address - Fax:
Practice Address - Street 1:186 TESNATEE LANDING DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-3874
Practice Address - Country:US
Practice Address - Phone:912-278-2729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
GALPC012657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty