Provider Demographics
NPI:1447302781
Name:FRECH, IDA R (LPC, CAC II)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:R
Last Name:FRECH
Suffix:
Gender:F
Credentials:LPC, CAC II
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:R
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 CAMRY CIR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-4216
Mailing Address - Country:US
Mailing Address - Phone:770-313-4048
Mailing Address - Fax:
Practice Address - Street 1:4399 E PAULDING DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-9510
Practice Address - Country:US
Practice Address - Phone:770-313-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003610101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional