Provider Demographics
NPI:1760229744
Name:FREDRICKS, HANNAH LANE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:HANNAH
Middle Name:LANE
Last Name:FREDRICKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:HANNAH
Other - Middle Name:JULIET
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PCSW
Mailing Address - Street 1:PO BOX 7005
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-7005
Mailing Address - Country:US
Mailing Address - Phone:334-444-2420
Mailing Address - Fax:
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-739-6124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-16811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical