Provider Demographics
NPI:1881405124
Name:FRAIDENBURG, MARK PERRY
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PERRY
Last Name:FRAIDENBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 LILLY RD NE APT 326
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5170
Mailing Address - Country:US
Mailing Address - Phone:360-986-1296
Mailing Address - Fax:
Practice Address - Street 1:1102 E MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3127
Practice Address - Country:US
Practice Address - Phone:253-339-6094
Practice Address - Fax:253-251-0716
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician