MEDICARE: MR. KENNETH L. FREDERICK LMFT

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	106H00000X	Marriage & Family Therapist	MT1560	FL

General Provider Information

NPI Number	:	1841406188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH L. FREDERICK LMFT

Provider Business Mailing Address
First Line	:	3868 NE 169TH ST APT 303
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-3210
Country	:	US
Telephone Number	:	954-958-0988
Fax Number	:	954-958-3527

Provider Business Practice Location Address
First Line	:	1925 S PERIMETER RD
Second Line	:	SUITE 120
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33309-7122
Country	:	US
Telephone Number	:	954-958-0988
Fax Number	:	954-958-3527

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

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	07/09/2007

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