Provider Demographics
NPI:1063628147
Name:FREDRICKSON, HAROLD W (HIS)
Entity Type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:W
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 25TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WI
Mailing Address - Zip Code:54822
Mailing Address - Country:US
Mailing Address - Phone:715-859-2927
Mailing Address - Fax:
Practice Address - Street 1:2621 E CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6726
Practice Address - Country:US
Practice Address - Phone:715-834-7111
Practice Address - Fax:715-834-7112
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI601237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42818300Medicaid