Provider Demographics
NPI:1902495351
Name:FREDRICKSON, RAYMOND GENE (LSWAIC, SUDPT, MSW)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:GENE
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:LSWAIC, SUDPT, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S FREYA ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4862
Mailing Address - Country:US
Mailing Address - Phone:509-964-1590
Mailing Address - Fax:
Practice Address - Street 1:104 S FREYA ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-4862
Practice Address - Country:US
Practice Address - Phone:509-964-1590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASA60844789104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker