| Doctor Name: | DR. SUSAN FREDRICKSON |
| NPI Number: | 1619305786 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PH.D. |
| License Number: | 629 |
| Business Practice Address: | 232 Rustling Willow St. Ute Mountain Ute Health Center Towaoc, CO - 813340049 |
| Business Phone Number: | 9705654441 |
| Business Fax Number: | 9705644784 |
| Mailing Address: | Po Box 49, Ute Mountain Ute Health Center TOWAOC |
| State: | CO |
| Postal Code: | 813340049 |
| Phone Number: | 9705654441 |
| Fax Number: | 9705644784 |
| NPI Enumeration Date: | 10/28/2013 |
| NPI Last Update Date: | 10/28/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 629 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |