MEDICARE: FRED H ELSEN LMSW

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	104100000X	Social Worker	LMSW3569	AZ

General Provider Information

NPI Number	:	1376792325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRED H ELSEN LMSW

Provider Business Mailing Address
First Line	:	105 N 5TH AVE
Second Line	:
City	:	HOLBROOK
State	:	AZ
Zip	:	86025-2817
Country	:	US
Telephone Number	:	928-524-6701
Fax Number	:	928-524-3068

Provider Business Practice Location Address
First Line	:	211 E THIRD ST
Second Line	:
City	:	WINSLOW
State	:	AZ
Zip	:	86047-3802
Country	:	US
Telephone Number	:	928-289-4658
Fax Number	:	928-289-3775

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

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	09/15/2008

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Directions to “ FRED H ELSEN LMSW” Practice Location

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