Provider Demographics
NPI:1376792325
Name:ELSEN, FRED H (LMSW)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:H
Last Name:ELSEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-2817
Mailing Address - Country:US
Mailing Address - Phone:928-524-6701
Mailing Address - Fax:928-524-3068
Practice Address - Street 1:211 E THIRD ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3802
Practice Address - Country:US
Practice Address - Phone:928-289-4658
Practice Address - Fax:928-289-3775
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW3569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker