Provider Demographics
NPI:1467601567
Name:FREDRICKSEN, WILLIAM J (PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:FREDRICKSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3817
Mailing Address - Country:US
Mailing Address - Phone:951-658-3121
Mailing Address - Fax:951-652-6994
Practice Address - Street 1:1515 W FLORIDA AVE
Practice Address - Street 2:SUITE E
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3817
Practice Address - Country:US
Practice Address - Phone:951-658-3121
Practice Address - Fax:951-652-6994
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 34922225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 34922OtherPT 34922