Healthcare Provider Details

I. General information

NPI: 1922142769
Provider Name (Legal Business Name): FRED A GIDEON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37491 ENTERPRISE DR A
BURNEY CA
96013-4379
US

IV. Provider business mailing address

PO BOX 496048
REDDING CA
96049-6048
US

V. Phone/Fax

Practice location:
  • Phone: 530-335-2906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: