Healthcare Provider Details

I. General information

NPI: 1487635363
Provider Name (Legal Business Name): JULIE D. FREDERICK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 SW WILSHIRE ST SUITE 160
PORTLAND OR
97225-5035
US

IV. Provider business mailing address

9900 SW WILSHIRE ST SUITE 160
PORTLAND OR
97225-5035
US

V. Phone/Fax

Practice location:
  • Phone: 503-894-9255
  • Fax: 503-385-0343
Mailing address:
  • Phone: 503-894-9255
  • Fax: 503-385-0343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1006
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: