Provider Demographics
NPI:1003042151
Name:WILFONG, FREDERICKA C (MDIV)
Entity type:Individual
Prefix:MRS
First Name:FREDERICKA
Middle Name:C
Last Name:WILFONG
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7729 PINEAPPLE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5311
Mailing Address - Country:US
Mailing Address - Phone:321-276-6692
Mailing Address - Fax:
Practice Address - Street 1:1009 MAITLAND CENTER COMMONS BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7270
Practice Address - Country:US
Practice Address - Phone:800-840-2528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT2141101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor