Provider Demographics
NPI:1487947578
Name:FREDERICK, TRISHA LYNN (MS)
Entity type:Individual
Prefix:MS
First Name:TRISHA
Middle Name:LYNN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:TRISHA
Other - Middle Name:LYNN
Other - Last Name:GAUERKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:12690 W. NORTH AVE.
Mailing Address - Street 2:BUILDING C
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4605
Mailing Address - Country:US
Mailing Address - Phone:262-785-1008
Mailing Address - Fax:262-785-0644
Practice Address - Street 1:12690 W. NORTH AVE.
Practice Address - Street 2:BUILDING C
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4605
Practice Address - Country:US
Practice Address - Phone:262-785-1008
Practice Address - Fax:262-785-0644
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1027-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional