Healthcare Provider Details

I. General information

NPI: 1689681298
Provider Name (Legal Business Name): AUDREY MAE FREDERICKSON PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 MAYWOOD RD SUITE 202
MOUND MN
55364-1775
US

IV. Provider business mailing address

5200 MAYWOOD RD SUITE 202
MOUND MN
55364-1775
US

V. Phone/Fax

Practice location:
  • Phone: 952-472-2408
  • Fax: 952-495-1409
Mailing address:
  • Phone: 952-472-2408
  • Fax: 952-495-1409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4856
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: