Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | 6301012365 | MI |
N | 103TC0700X | Clinical Psychologist | 6301012365 | MI |
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 6301012365 | MI |
NPI | 1033225420 |
---|---|
Provider Name | Emily M Fredericks |
First Address | Ann Arbor, MI 48108-1633 |
Second Address | Ann Arbor, MI 48109-5000 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2006 |
Last Update Date | 19/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q56227 | (02) | MI |