Basic Information
| Provider Information | |||||||||
| NPI: | 1033449053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDRICKSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW-PIP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 FAIRMONT BLVD | ||||||||
| Address2: | ATTEN CHRISTIE MSS | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577017350 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 353 FAIRMONT BLVD. | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057192300 | ||||||||
| FaxNumber: | 6057192310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2010 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2423 | SD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.