MEDICARE: FREDERICK L HERCHUK LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	ISW04711	RI

General Provider Information

NPI Number	:	1457208423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK L HERCHUK LICSW

Provider Business Mailing Address
First Line	:	70 PANTO RD
Second Line	:
City	:	WARWICK
State	:	RI
Zip	:	02886-0633
Country	:	US
Telephone Number	:	401-444-4005
Fax Number	:	401-444-5715

Provider Business Practice Location Address
First Line	:	70 PANTO RD
Second Line	:
City	:	WARWICK
State	:	RI
Zip	:	02886-0633
Country	:	US
Telephone Number	:	401-444-4005
Fax Number	:	401-444-5715

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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