Provider Demographics
NPI:1639539380
Name:FREDRICKS, TANYA ROBIN GIBSONE (MPT, CEEAA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:ROBIN GIBSONE
Last Name:FREDRICKS
Suffix:
Gender:F
Credentials:MPT, CEEAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 SAN FRANCISCO BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1639
Mailing Address - Country:US
Mailing Address - Phone:415-256-1797
Mailing Address - Fax:
Practice Address - Street 1:220 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2416
Practice Address - Country:US
Practice Address - Phone:415-457-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA217532251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic