Provider Demographics
NPI:1871747790
Name:MEDWAY, FREDERIC J (PHD)
Entity type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:J
Last Name:MEDWAY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 ASSEMBLY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2142
Mailing Address - Country:US
Mailing Address - Phone:803-920-2412
Mailing Address - Fax:
Practice Address - Street 1:2016 ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2142
Practice Address - Country:US
Practice Address - Phone:803-920-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC#224103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist