Healthcare Provider Details

I. General information

NPI: 1114077864
Provider Name (Legal Business Name): BRENDA JOY FRICKE MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S ELM BOX 798
DIXON MO
65459
US

IV. Provider business mailing address

25945 SANDLEWOOD LN PO BOX 175
LAQUEY MO
65534-7615
US

V. Phone/Fax

Practice location:
  • Phone: 573-528-3558
  • Fax: 573-774-6992
Mailing address:
  • Phone: 573-528-3558
  • Fax: 573-774-6992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2003002001
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: