Provider Demographics
NPI:1366273468
Name:FREDERICKSON, DANIELLE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MAUSERT CT APT B
Mailing Address - Street 2:
Mailing Address - City:COLEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96107-9408
Mailing Address - Country:US
Mailing Address - Phone:619-739-3832
Mailing Address - Fax:
Practice Address - Street 1:101 MAUSERT CT APT B
Practice Address - Street 2:
Practice Address - City:COLEVILLE
Practice Address - State:CA
Practice Address - Zip Code:96107-9408
Practice Address - Country:US
Practice Address - Phone:619-739-3832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-10
Last Update Date:2024-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37769235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty