Provider Demographics
NPI:1033449053
Name:FREDRICKSON, MARY ANN (LCSW-PIP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:LCSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MOUNT RUSHMORE RD STE 3
Mailing Address - Street 2:#202
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:210-846-9037
Mailing Address - Fax:
Practice Address - Street 1:1601 MOUNT RUSHMORE RD STE 3
Practice Address - Street 2:#202
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:210-846-9037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD24231041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical