Provider Demographics
NPI:1902077589
Name:FREDRICKSON, TAMMY L
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3573
Mailing Address - Country:US
Mailing Address - Phone:303-440-3050
Mailing Address - Fax:303-440-3170
Practice Address - Street 1:2750 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3573
Practice Address - Country:US
Practice Address - Phone:303-440-3050
Practice Address - Fax:303-440-3170
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO503231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist