Provider Demographics
NPI:1093140386
Name:FREDERICKSEN, DONALD DARYL (MPT)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:DARYL
Last Name:FREDERICKSEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-3073
Mailing Address - Country:US
Mailing Address - Phone:509-780-2111
Mailing Address - Fax:
Practice Address - Street 1:1727 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-3073
Practice Address - Country:US
Practice Address - Phone:509-780-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist