Provider Demographics
NPI:1457009805
Name:FREDRICKSEN, PEYTON (PT,DPT)
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:
Last Name:FREDRICKSEN
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12615 OLD SILO TRL SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803-3342
Mailing Address - Country:US
Mailing Address - Phone:256-479-9531
Mailing Address - Fax:
Practice Address - Street 1:12615 OLD SILO TRL SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35803-3342
Practice Address - Country:US
Practice Address - Phone:256-479-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH9182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist