Basic Information
Provider Information
NPI: 1033557350
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FREDERICK
FirstName: GARNETT
MiddleName: N
NamePrefix: DR.
NameSuffix:  
Credential: PHD, MSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 17008 SW 64TH CT
Address2:  
City: SOUTHWEST RANCHES
State: FL
PostalCode: 333311762
CountryCode: US
TelephoneNumber: 9546896687
FaxNumber:  
Practice Location
Address1: 1201 NW 16TH ST
Address2:  
City: MIAMI
State: FL
PostalCode: 331251624
CountryCode: US
TelephoneNumber: 3055757000
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/08/2013
LastUpdateDate: 06/08/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X  Y Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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