Provider Demographics
NPI:1497068068
Name:FREDENBURG, BRIAN EARL (MFT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EARL
Last Name:FREDENBURG
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 S ANITA DR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3355
Mailing Address - Country:US
Mailing Address - Phone:714-978-1090
Mailing Address - Fax:
Practice Address - Street 1:265 S ANITA DR
Practice Address - Street 2:SUITE 117
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3355
Practice Address - Country:US
Practice Address - Phone:714-978-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC22198106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist