=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376220921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDERICK JOSHUA LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2023
-----------------------------------------------------
Last Update Date | 09/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI 1 MISUMI MACHI, IWAKUNI
-----------------------------------------------------
City | IWAKUNI
-----------------------------------------------------
State | YAMAGUCHI
-----------------------------------------------------
Zip | 7400025
-----------------------------------------------------
Country | JP
-----------------------------------------------------
Telephone | 443-627-1079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PSC 561 BOX 1877
-----------------------------------------------------
City | FPO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96310-0014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------