Provider Demographics
NPI:1285188375
Name:FREDENBURG, TYWANA ROSZEL (LLBSW)
Entity Type:Individual
Prefix:MRS
First Name:TYWANA
Middle Name:ROSZEL
Last Name:FREDENBURG
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 BROWNING CT APT 2
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3924
Mailing Address - Country:US
Mailing Address - Phone:734-904-0071
Mailing Address - Fax:
Practice Address - Street 1:30000 HIVELEY ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1089
Practice Address - Country:US
Practice Address - Phone:734-728-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020875941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical