Healthcare Provider Details

I. General information

NPI: 1336988930
Provider Name (Legal Business Name): SAMUEL FREDRICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 DONOFRIO DR STE 206
MADISON WI
53719-2839
US

IV. Provider business mailing address

563 STONEWOOD CT
EVANSVILLE WI
53536-9001
US

V. Phone/Fax

Practice location:
  • Phone: 608-424-9100
  • Fax:
Mailing address:
  • Phone: 920-960-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: