Individual
THEA RENEE FREDERICKSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.A., OTR/L
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
14082
CA
225X00000X
Occupational Therapist
Primary
104473
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
104473
MN OT LICENSE
MN
01
—
14082
CALIFORNIA BOARD OF OCCUPATIONAL THERAPY
CA
01
—
309557
NATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY
MN
Enumeration date
06/10/2014
Last updated
06/08/2026
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