=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386145332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN SCOTT FREDERICK LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2018
-----------------------------------------------------
Last Update Date | 01/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 186 TESNATEE LANDING DR
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30528-3874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-278-2729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 186 TESNATEE LANDING DR
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30528-3874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-278-2729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC012657
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------