Provider Demographics
NPI:1447286208
Name:FREDERICK, ANDREW JAY (LICSW)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAY
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 CYPRESS ST STE 7
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3600
Mailing Address - Country:US
Mailing Address - Phone:603-663-8650
Mailing Address - Fax:
Practice Address - Street 1:445 CYPRESS ST STE 7
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103
Practice Address - Country:US
Practice Address - Phone:603-663-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical