Provider Demographics
NPI:1427558881
Name:FRERICKS, SUSAN ANNE
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANNE
Last Name:FRERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-8635
Mailing Address - Country:US
Mailing Address - Phone:425-238-6990
Mailing Address - Fax:
Practice Address - Street 1:2609 N 30TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-8635
Practice Address - Country:US
Practice Address - Phone:425-238-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60827890225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist