MEDICARE: DR. AUDREY MAE FREDERICKSON PSY D

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	103TC0700X	Clinical Psychologist	4856	MN

General Provider Information

NPI Number	:	1689681298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUDREY MAE FREDERICKSON PSY D

Provider Business Mailing Address
First Line	:	5200 MAYWOOD RD
Second Line	:	SUITE 202
City	:	MOUND
State	:	MN
Zip	:	55364-1775
Country	:	US
Telephone Number	:	952-472-2408
Fax Number	:	952-495-1409

Provider Business Practice Location Address
First Line	:	5200 MAYWOOD RD
Second Line	:	SUITE 202
City	:	MOUND
State	:	MN
Zip	:	55364-1775
Country	:	US
Telephone Number	:	952-472-2408
Fax Number	:	952-495-1409

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

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	11/13/2009

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