Provider Demographics
NPI:1568745545
Name:FREDERIKSEN, PAUL B (PHD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:B
Last Name:FREDERIKSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:601-705-1952
Practice Address - Street 1:103 SOUTH 19TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-544-4641
Practice Address - Fax:601-582-1602
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS51 886103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical