MEDICARE: MR. CLINTON PAUL FREDERICKSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	2793-C	NV

General Provider Information

NPI Number	:	1982714457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLINTON PAUL FREDERICKSON LCSW

Provider Business Mailing Address
First Line	:	1501 ARVILLE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-3838
Country	:	US
Telephone Number	:	702-259-4646
Fax Number	:	702-259-7791

Provider Business Practice Location Address
First Line	:	1501 ARVILLE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-3838
Country	:	US
Telephone Number	:	702-259-4646
Fax Number	:	702-259-7791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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