MEDICARE: ROBERT FREDRICKSON III LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1346999208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT FREDRICKSON III LPC

Provider Business Mailing Address
First Line	:	25931 484TH AVE
Second Line	:
City	:	VALLEY SPRINGS
State	:	SD
Zip	:	57068-6602
Country	:	US
Telephone Number	:	605-212-3772
Fax Number	:

Provider Business Practice Location Address
First Line	:	25931 484TH AVE
Second Line	:
City	:	VALLEY SPRINGS
State	:	SD
Zip	:	57068-6602
Country	:	US
Telephone Number	:	605-212-3772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2022
Last Update Date	:	03/19/2022

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