MEDICARE: BRIAN PAUL FREDERICK PH.D.

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	103T00000X	Psychologist	880	LA
2	103T00000X	Psychologist	40-005	MS

General Provider Information

NPI Number	:	1902965742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN PAUL FREDERICK PH.D.

Provider Business Mailing Address
First Line	:	305 MILL POND DR
Second Line	:
City	:	YOUNGSVILLE
State	:	LA
Zip	:	70592-5655
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 KALISTE SALOOM RD
Second Line	:	SUITE 105
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-4230
Country	:	US
Telephone Number	:	337-237-0788
Fax Number	:	337-237-0785

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

Provider Enumeration Date	:	12/07/2006
Last Update Date	:	07/08/2007

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