MEDICARE: MISS CAROLYN MARIE FREDRICK LPC

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	101YM0800X	Mental Health Counselor	2002001642	MO

General Provider Information

NPI Number	:	1336262963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CAROLYN MARIE FREDRICK LPC

Provider Business Mailing Address
First Line	:	4609 CHARLOTTE ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64110-1521
Country	:	US
Telephone Number	:	816-507-0582
Fax Number	:	816-561-7457

Provider Business Practice Location Address
First Line	:	4609 CHARLOTTE ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64110-1521
Country	:	US
Telephone Number	:	816-507-0582
Fax Number	:	816-561-7457

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	07/08/2007

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