Provider Demographics
NPI:1619617636
Name:PEDERSON, ABIGAIL R (LAC)
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:R
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 N WAKONDA ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7894
Mailing Address - Country:US
Mailing Address - Phone:520-404-7993
Mailing Address - Fax:
Practice Address - Street 1:460 N SWITZER CANYON DR STE 400
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4851
Practice Address - Country:US
Practice Address - Phone:928-421-4184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional