Provider Demographics
NPI:1730379207
Name:FREDERICK, LANCE ANDREW (MFT)
Entity type:Individual
Prefix:MR
First Name:LANCE
Middle Name:ANDREW
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7567 AMADOR VALLEY BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2443
Mailing Address - Country:US
Mailing Address - Phone:510-582-1951
Mailing Address - Fax:
Practice Address - Street 1:7567 AMADOR VALLEY BLVD STE 202
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2443
Practice Address - Country:US
Practice Address - Phone:510-582-1951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC14622106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist