Healthcare Provider Details

I. General information

NPI: 1073175733
Provider Name (Legal Business Name): LAURA ELIZABETH FREDERICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 W. JACKMAN ST.
LANCASTER CA
93534-2531
US

IV. Provider business mailing address

506 W. JACKMAN ST.
LANCASTER CA
93534-2531
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-2850
  • Fax: 661-726-2854
Mailing address:
  • Phone: 661-726-2850
  • Fax: 661-726-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120336
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: