Provider Demographics
NPI:1346322419
Name:FREDRICKSON, DANIELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HOW LN
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-3653
Mailing Address - Country:US
Mailing Address - Phone:732-993-9762
Mailing Address - Fax:732-626-4544
Practice Address - Street 1:123 HOW LANE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:732-993-9762
Practice Address - Fax:732-626-4544
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00224200101YA0400X
NY067712-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0404471Medicaid