Provider Demographics
NPI:1871376764
Name:FREDERICK, ERICKA TIPHANY (SCL, LLC)
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:TIPHANY
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:SCL, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31278 SCHOENHERR RD APT 5
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-1943
Mailing Address - Country:US
Mailing Address - Phone:313-658-5133
Mailing Address - Fax:
Practice Address - Street 1:29425 NORTHWESTERN HWY STE 215
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1000
Practice Address - Country:US
Practice Address - Phone:248-327-7409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023222101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor