=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275251266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERICK THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2022
-----------------------------------------------------
Last Update Date | 08/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 316 VILLA DR # 4774
-----------------------------------------------------
City | BOX ELDER
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57719-2023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-471-8822
-----------------------------------------------------
Fax | 443-957-9004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 147 RAINBOW DR # 4774
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77399-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-471-8822
-----------------------------------------------------
Fax | 443-957-9004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST/OWNER
-----------------------------------------------------
Name | MRS. MEREDITH ANDREWS MCADAM
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 240-575-1810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------