Healthcare Provider Details

I. General information

NPI: 1720089915
Provider Name (Legal Business Name): LINDA R FREDERICK CADC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

IV. Provider business mailing address

121 S PRAIRIE ST
PRAIRIE DU CHIEN WI
53821-1418
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0940
  • Fax:
Mailing address:
  • Phone: 608-326-1770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: