Provider Demographics
NPI:1184322562
Name:FREDERICK, EMILY (LSW)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 RAINELLE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LANESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47136-9474
Mailing Address - Country:US
Mailing Address - Phone:812-887-7474
Mailing Address - Fax:
Practice Address - Street 1:1060 SHARON DR
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4522
Practice Address - Country:US
Practice Address - Phone:812-283-7116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33011271A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN121010837799Medicaid