Provider Demographics
NPI:1033449053
Name:FREDRICKSON, MARY ANN (LCSW-PIP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:LCSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN CHRISTIE MSS
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:353 FAIRMONT BLVD.
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-719-2300
Practice Address - Fax:605-719-2310
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD24231041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical