MEDICARE: DR. RANDI FREDRICKS PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	47803	CA

General Provider Information

NPI Number	:	1679889794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDI FREDRICKS PHD

Provider Business Mailing Address
First Line	:	PO BOX 8252
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95155-8252
Country	:	US
Telephone Number	:	408-315-0645
Fax Number	:

Provider Business Practice Location Address
First Line	:	1174 LINCOLN AVE STE 6
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-3029
Country	:	US
Telephone Number	:	408-315-0645
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2010
Last Update Date	:	07/01/2011

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