Provider Demographics
NPI:1598542011
Name:FREDERICKSON, MAESER GLEYRE (LMSW)
Entity Type:Individual
Prefix:
First Name:MAESER
Middle Name:GLEYRE
Last Name:FREDERICKSON
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 1:196 N 1900 E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2903
Mailing Address - Country:US
Mailing Address - Phone:208-569-6620
Mailing Address - Fax:
Practice Address - Street 1:2267 TETON PLZ
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6486
Practice Address - Country:US
Practice Address - Phone:208-522-0140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker