Provider Demographics
NPI:1700950557
Name:FREDERICKSEN, GARY J (LICSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:J
Last Name:FREDERICKSEN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4422 6TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1020
Mailing Address - Country:US
Mailing Address - Phone:360-704-7170
Mailing Address - Fax:360-412-4982
Practice Address - Street 1:4422 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1020
Practice Address - Country:US
Practice Address - Phone:360-704-7170
Practice Address - Fax:360-412-4982
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00004165101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8804265Medicare ID - Type UnspecifiedMEDICARE ID NUMBER