Healthcare Provider Details

I. General information

NPI: 1053715920
Provider Name (Legal Business Name): AMY FREDERICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490B W ZIA RD SUITE 4
SANTA FE NM
87505-7008
US

IV. Provider business mailing address

490B W ZIA RD SUITE 4
SANTA FE NM
87505-7008
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-3820
  • Fax: 505-913-3829
Mailing address:
  • Phone: 505-913-3820
  • Fax: 505-913-3829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-07517
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: