Provider Demographics
NPI:1376510412
Name:FREDRICKS, MARY LAVINA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LAVINA
Last Name:FREDRICKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04254
Mailing Address - Country:US
Mailing Address - Phone:207-897-6601
Mailing Address - Fax:207-897-4339
Practice Address - Street 1:38 UNION ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE FALLS
Practice Address - State:ME
Practice Address - Zip Code:04254
Practice Address - Country:US
Practice Address - Phone:207-897-6601
Practice Address - Fax:207-897-4339
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME1293651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME218840099Medicaid
ME047005OtherANTHEM