Provider Demographics
NPI:1104180520
Name:FREDRICKSON, MICK (LCSW)
Entity Type:Individual
Prefix:
First Name:MICK
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 2ND AVE SW STE 102
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-2483
Mailing Address - Country:US
Mailing Address - Phone:541-286-3209
Mailing Address - Fax:541-704-0040
Practice Address - Street 1:425 2ND AVE SW STE 102
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-2483
Practice Address - Country:US
Practice Address - Phone:541-286-3209
Practice Address - Fax:541-704-0040
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL67431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500710040Medicaid