MEDICARE: MATTHEW RICHARD FREDERICK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1475-C	AR

General Provider Information

NPI Number	:	1184646432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW RICHARD FREDERICK LCSW

Provider Business Mailing Address
First Line	:	2001 CLUB MANOR DR STE J
Second Line	:
City	:	MAUMELLE
State	:	AR
Zip	:	72113-7417
Country	:	US
Telephone Number	:	501-687-0488
Fax Number	:	501-687-0489

Provider Business Practice Location Address
First Line	:	2001 CLUB MANOR DR STE J
Second Line	:
City	:	MAUMELLE
State	:	AR
Zip	:	72113-7417
Country	:	US
Telephone Number	:	501-687-0488
Fax Number	:	501-687-0489

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	03/23/2016

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