Healthcare Provider Details

I. General information

NPI: 1215443049
Provider Name (Legal Business Name): FREDERICK MARCUS VICKERY LPPC, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

8170 33RD AVENUE MAILSTOP 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1835
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304457
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: