Provider Demographics
NPI:1699789073
Name:BREDEFELD, GARRY (PHD)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:
Last Name:BREDEFELD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 E LOYOLA AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-1641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5100 N 6TH ST STE 130
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7515
Practice Address - Country:US
Practice Address - Phone:559-226-1217
Practice Address - Fax:559-434-6316
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY-9707103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL97070Medicare ID - Type Unspecified