Provider Demographics
NPI:1598178204
Name:FREDERICKSEN, THEA RENEE (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:RENEE
Last Name:FREDERICKSEN
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 CALLE AMANECER
Mailing Address - Street 2:STE A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 CALLE AMANECER
Practice Address - Street 2:STE A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6250
Practice Address - Country:US
Practice Address - Phone:949-498-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14082174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14082OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY
MN309557OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY