Provider Demographics
NPI:1104833938
Name:FREDENBURG, BRUCE ROBERT (LMFT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ROBERT
Last Name:FREDENBURG
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-0808
Mailing Address - Country:US
Mailing Address - Phone:949-338-2218
Mailing Address - Fax:949-855-1388
Practice Address - Street 1:17542 IRVINE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3155
Practice Address - Country:US
Practice Address - Phone:714-508-1919
Practice Address - Fax:714-508-1935
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC17319106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist