Healthcare Provider Details

I. General information

NPI: 1104749068
Provider Name (Legal Business Name): KIM FREDRICKS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W GRANADA BLVD STE 4
ORMOND BEACH FL
32174-8157
US

IV. Provider business mailing address

1200 W GRANADA BLVD STE 4
ORMOND BEACH FL
32174-8157
US

V. Phone/Fax

Practice location:
  • Phone: 386-983-4147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberRN9508898
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberRN9508898
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberRN9508898
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberRN9508898
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License NumberRN9508898
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: