Healthcare Provider Details

I. General information

NPI: 1225014699
Provider Name (Legal Business Name): RODNEY D FREEBORG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S 8TH ST STE G20
SHEBOYGAN WI
53081-4405
US

IV. Provider business mailing address

615 S 8TH ST STE G20
SHEBOYGAN WI
53081-4405
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-8866
  • Fax: 920-457-8867
Mailing address:
  • Phone: 920-457-8866
  • Fax: 920-457-8867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number81057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: