Provider Demographics
NPI:1023360989
Name:FREDERICKS, STACEY LYNN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 W 95TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2574
Mailing Address - Country:US
Mailing Address - Phone:708-684-7999
Mailing Address - Fax:
Practice Address - Street 1:4700 W 95TH ST STE 205
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2574
Practice Address - Country:US
Practice Address - Phone:708-684-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL149.0253341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program