Provider Demographics
NPI:1508211467
Name:FREDERICKSEN, BROOKLYNN J (LICSW)
Entity Type:Individual
Prefix:
First Name:BROOKLYNN
Middle Name:J
Last Name:FREDERICKSEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 977
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-0977
Mailing Address - Country:US
Mailing Address - Phone:507-446-0431
Mailing Address - Fax:507-446-8014
Practice Address - Street 1:2575 HARVEST LN
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4305
Practice Address - Country:US
Practice Address - Phone:507-446-0431
Practice Address - Fax:507-446-8014
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN226801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical