Basic Information
| Provider Information | |||||||||
| NPI: | 1356725162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | RACHAEL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, SAC-IT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOZER | ||||||||
| OtherFirstName: | RACHAEL | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | W17634 RADKE RD | ||||||||
| Address2: | |||||||||
| City: | WITTENBERG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544995100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152536064 | ||||||||
| FaxNumber: | 7152532897 | ||||||||
| Practice Location | |||||||||
| Address1: | W17634 RADKE RD | ||||||||
| Address2: | |||||||||
| City: | WITTENBERG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544995100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152536064 | ||||||||
| FaxNumber: | 7152532897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2015 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 18118 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 9088 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100046416 | 05 | WI | MEDICAID |