Healthcare Provider Details

I. General information

NPI: 1700896453
Provider Name (Legal Business Name): ALEXANDR MICHAL FEDERER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S. MCQUEEN ST
FLORENCE SC
29501
US

IV. Provider business mailing address

323 S. MCQUEEN ST
FLORENCE SC
29501
US

V. Phone/Fax

Practice location:
  • Phone: 843-992-2149
  • Fax: 843-992-2149
Mailing address:
  • Phone: 843-992-2149
  • Fax: 843-661-5588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number569
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number569
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: