Provider Demographics
NPI:1992076988
Name:ROBERT M. FREDRICK, LCSW,PC
Entity type:Organization
Organization Name:ROBERT M. FREDRICK, LCSW,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:FREDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:404-636-1108
Mailing Address - Street 1:2801 BUFORD HWY NE
Mailing Address - Street 2:SUITE 508
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2149
Mailing Address - Country:US
Mailing Address - Phone:404-636-1108
Mailing Address - Fax:404-636-9482
Practice Address - Street 1:2801 BUFORD HWY NE
Practice Address - Street 2:SUITE 508
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2149
Practice Address - Country:US
Practice Address - Phone:404-636-1108
Practice Address - Fax:404-636-9482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0001441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty