Provider Demographics
NPI:1902096498
Name:FREDERICK, RYAN M (LPC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 ENTERPRISE DR 300
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-8982
Mailing Address - Country:US
Mailing Address - Phone:479-717-7626
Mailing Address - Fax:479-717-7627
Practice Address - Street 1:515 ENTERPRISE DR 300
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-8982
Practice Address - Country:US
Practice Address - Phone:479-717-7626
Practice Address - Fax:479-717-7627
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1509105101YP2500X
TX60422101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184696601Medicaid