Provider Demographics
NPI:1538682646
Name:FREDMAN, DAVID (MAMFT, MED)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FREDMAN
Suffix:
Gender:M
Credentials:MAMFT, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 EXCELSIOR BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5407 EXCELSIOR BLVD STE B
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2932
Practice Address - Country:US
Practice Address - Phone:952-220-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist