Provider Demographics
NPI:1851641047
Name:FREDRICKSON, SAUNDRA L (MA)
Entity Type:Individual
Prefix:
First Name:SAUNDRA
Middle Name:L
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6202 CONSTITUTION DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1583
Mailing Address - Country:US
Mailing Address - Phone:260-432-0066
Mailing Address - Fax:260-432-8503
Practice Address - Street 1:6202 CONSTITUTION DR
Practice Address - Street 2:SUITE D
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1583
Practice Address - Country:US
Practice Address - Phone:260-432-0066
Practice Address - Fax:260-432-8503
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002773A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health