Provider Demographics
NPI:1407067275
Name:FREDERIKSEN, KATHLEEN (LMSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FREDERIKSEN
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 1:25600 WOODWARD AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0945
Mailing Address - Country:US
Mailing Address - Phone:248-840-9517
Mailing Address - Fax:
Practice Address - Street 1:25600 WOODWARD AVE STE 204
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067
Practice Address - Country:US
Practice Address - Phone:248-794-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010868031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical