Healthcare Provider Details

I. General information

NPI: 1548224744
Provider Name (Legal Business Name): SUSAN M FREDRICKSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W HWY 50 SUITE 104
CLERMONT FL
34711-2913
US

IV. Provider business mailing address

2950 PLAZA TERRACE DR
ORLANDO FL
32803-2825
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-5922
  • Fax: 352-360-6582
Mailing address:
  • Phone: 352-394-5922
  • Fax: 352-360-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberMH 4648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: