Provider Demographics
NPI:1902312655
Name:FREDERICKS, CHARLES R (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:FREDERICKS
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 1:1049 BROADWAY STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1335
Mailing Address - Country:US
Mailing Address - Phone:732-222-1100
Mailing Address - Fax:732-222-1103
Practice Address - Street 1:1049 BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1335
Practice Address - Country:US
Practice Address - Phone:732-222-1100
Practice Address - Fax:732-222-1103
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100267600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical