Provider Demographics
NPI:1497769400
Name:BAX, FREDA BRIGITTE (PSYD)
Entity Type:Individual
Prefix:
First Name:FREDA
Middle Name:BRIGITTE
Last Name:BAX
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2686
Mailing Address - Country:US
Mailing Address - Phone:503-232-1670
Mailing Address - Fax:503-764-9646
Practice Address - Street 1:847 NE 19TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2686
Practice Address - Country:US
Practice Address - Phone:502-232-1670
Practice Address - Fax:503-764-9646
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1568103TH0100X, 103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029055Medicaid
OR500655961Medicaid