Provider Demographics
NPI:1124323118
Name:FREDETTE, MELISSA (PHD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:FREDETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 SE ELLIOTT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5341
Mailing Address - Country:US
Mailing Address - Phone:503-396-2638
Mailing Address - Fax:503-689-8686
Practice Address - Street 1:1235 SE DIVISION ST STE 109
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1042
Practice Address - Country:US
Practice Address - Phone:503-343-9939
Practice Address - Fax:503-689-8686
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9838103T00000X
OR2156103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
ORR0000WDBCHOtherMEDICARE GROUP