Provider Demographics
NPI:1619575917
Name:FREDERIKSEN, BRITTANY (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:FREDERIKSEN
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PICCADILLY PL APT 11
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-2031
Mailing Address - Country:US
Mailing Address - Phone:650-270-6679
Mailing Address - Fax:
Practice Address - Street 1:415 PICCADILLY PL APT 11
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2031
Practice Address - Country:US
Practice Address - Phone:650-270-6679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-16-23081103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst