MEDICARE: FREDERICK WILLIAM RISARD

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	79759	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	76759	OTHER	CA	BOARD OF BEHAVIORAL SCIENCES

General Provider Information

NPI Number	:	1912217837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK WILLIAM RISARD

Provider Business Mailing Address
First Line	:	5001 3RD AVE
Second Line	:
City	:	MARINA
State	:	CA
Zip	:	93933-4529
Country	:	US
Telephone Number	:	209-658-9832
Fax Number	:

Provider Business Practice Location Address
First Line	:	9829 BLUE LARKSPUR LN
Second Line	:
City	:	MONTEREY
State	:	CA
Zip	:	93940-6535
Country	:	US
Telephone Number	:	209-658-9832
Fax Number	:

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

Provider Enumeration Date	:	10/13/2010
Last Update Date	:	01/17/2022

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