Provider Demographics
NPI:1689952954
Name:FREDRICKSON, ANGELA (LSW)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 PRINCEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-8704
Mailing Address - Country:US
Mailing Address - Phone:214-235-6679
Mailing Address - Fax:
Practice Address - Street 1:5072 W PLANO PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4476
Practice Address - Country:US
Practice Address - Phone:972-818-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50070104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX50070OtherLICENSE