Provider Demographics
NPI:1053715920
Name:FREDERICKS, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490B W ZIA RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7008
Mailing Address - Country:US
Mailing Address - Phone:505-913-3820
Mailing Address - Fax:505-913-3829
Practice Address - Street 1:490B W ZIA RD
Practice Address - Street 2:SUITE 4
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7008
Practice Address - Country:US
Practice Address - Phone:505-913-3820
Practice Address - Fax:505-913-3829
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07517104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker