Provider Demographics
NPI:1053606657
Name:FREDERIKSEN, KALA M (PT)
Entity type:Individual
Prefix:
First Name:KALA
Middle Name:M
Last Name:FREDERIKSEN
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:KALA
Other - Middle Name:
Other - Last Name:PLANTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:42369 CRESTVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-3266
Mailing Address - Country:US
Mailing Address - Phone:515-231-7057
Mailing Address - Fax:
Practice Address - Street 1:42369 CRESTVIEW CIR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-3266
Practice Address - Country:US
Practice Address - Phone:515-231-7057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11819-24225100000X
IA077175225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053606657Medicaid
WI832070040Medicare PIN
WI1053606657Medicaid