Provider Demographics
NPI:1891923272
Name:PEDERSON, GINGER LYN (LICSW)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:LYN
Last Name:PEDERSON
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 1:1201 25TH ST S
Mailing Address - Street 2:PO BOX 9859
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2311
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:701-451-4893
Practice Address - Street 1:3950 3RD ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4033
Practice Address - Country:US
Practice Address - Phone:320-253-5930
Practice Address - Fax:320-258-4632
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical