Healthcare Provider Details

I. General information

NPI: 1124128459
Provider Name (Legal Business Name): KATHRYN FRASER PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

IV. Provider business mailing address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

V. Phone/Fax

Practice location:
  • Phone: 386-254-4165
  • Fax: 386-254-4349
Mailing address:
  • Phone: 386-254-4165
  • Fax: 386-254-4349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY5411
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: