Provider Demographics
NPI:1053701177
Name:FRICK, MIYA M (MSC, LCGC)
Entity type:Individual
Prefix:MS
First Name:MIYA
Middle Name:M
Last Name:FRICK
Suffix:
Gender:F
Credentials:MSC, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 DIVISADERO ST BOX 1714
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:415-885-7779
Mailing Address - Fax:
Practice Address - Street 1:1600 DIVISADERO ST BOX 1714
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0001
Practice Address - Country:US
Practice Address - Phone:415-885-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC000553170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS