Provider Demographics
NPI:1417257759
Name:FREDERICK, KATHLEEN A (LICSW, CACII)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LICSW, CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 SW US VETERANS HOSPITAL ROAD
Mailing Address - Street 2:P.O.BOX 1035
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207
Mailing Address - Country:US
Mailing Address - Phone:360-696-4061
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97207
Practice Address - Country:US
Practice Address - Phone:360-696-4061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6333101YA0400X
CO12491041C0700X
WALW 602485021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)