Provider Demographics
NPI:1578305413
Name:FREDRICKSON, DYLAN JOSEPH (PT, DPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:JOSEPH
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5432 CARPINTERIA AVE
Practice Address - Street 2:
Practice Address - City:CARPINTERIA
Practice Address - State:CA
Practice Address - Zip Code:93013-1423
Practice Address - Country:US
Practice Address - Phone:805-566-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306060225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist