Provider Demographics
NPI:1699042572
Name:FREDERIKSEN, SARA (BCBA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:FREDERIKSEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18726 S WESTERN AVE
Mailing Address - Street 2:STE. 408
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3813
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:310-324-3134
Practice Address - Street 1:18726 S WESTERN AVE
Practice Address - Street 2:STE. 408
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3813
Practice Address - Country:US
Practice Address - Phone:310-856-0800
Practice Address - Fax:310-324-3134
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-10-7327103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst