Provider Demographics
NPI:1598386187
Name:FREDRICKS, ALYSSA M (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:M
Last Name:FREDRICKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 N CLAY ST UNIT 502
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5193
Mailing Address - Country:US
Mailing Address - Phone:561-843-3733
Mailing Address - Fax:
Practice Address - Street 1:710 BURBANK ST
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1658
Practice Address - Country:US
Practice Address - Phone:720-387-8458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005180103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist