Provider Demographics
NPI:1710765235
Name:FREDERICKSON, REBECCA SUE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2833 HOOVER AVE NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3789
Mailing Address - Country:US
Mailing Address - Phone:503-516-0631
Mailing Address - Fax:
Practice Address - Street 1:2833 HOOVER AVE NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3789
Practice Address - Country:US
Practice Address - Phone:503-516-0631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician