Healthcare Provider Details

I. General information

NPI: 1568745545
Provider Name (Legal Business Name): PAUL B FREDERIKSEN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 SOUTH 19TH AVE
HATTIESBURG MS
39402
US

IV. Provider business mailing address

P O BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-4641
  • Fax: 601-582-1602
Mailing address:
  • Phone: 601-705-1901
  • Fax: 601-705-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number51 886
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: