Provider Demographics
NPI:1407951809
Name:FREDRICKSON, KRISTIN (MA MFT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 JONES WAY
Mailing Address - Street 2:#21
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1203
Mailing Address - Country:US
Mailing Address - Phone:805-527-9587
Mailing Address - Fax:805-527-9588
Practice Address - Street 1:2650 JONES WAY
Practice Address - Street 2:#21
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1203
Practice Address - Country:US
Practice Address - Phone:805-527-9587
Practice Address - Fax:805-527-9588
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15273106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist