Provider Demographics
NPI:1992258560
Name:UPTON, FREDERICK WARREN (PHD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:WARREN
Last Name:UPTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 S MAPLE RD # 2
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3838
Mailing Address - Country:US
Mailing Address - Phone:734-368-9691
Mailing Address - Fax:
Practice Address - Street 1:635 S MAPLE RD # 2
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103
Practice Address - Country:US
Practice Address - Phone:734-238-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017268103T00000X
MI6301015567390200000X
MI6301017920103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program