Healthcare Provider Details

I. General information

NPI: 1902096498
Provider Name (Legal Business Name): RYAN M FREDERICK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 ENTERPRISE DR 300
LOWELL AR
72745-8982
US

IV. Provider business mailing address

515 ENTERPRISE DR 300
LOWELL AR
72745-8982
US

V. Phone/Fax

Practice location:
  • Phone: 479-717-7626
  • Fax: 479-717-7627
Mailing address:
  • Phone: 479-717-7626
  • Fax: 479-717-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1509105
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: