Provider Demographics
NPI:1215443049
Name:VICKERY, FREDERICK MARCUS (LPC, LADC)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:MARCUS
Last Name:VICKERY
Suffix:
Gender:M
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1052
Mailing Address - Country:US
Mailing Address - Phone:952-993-6200
Mailing Address - Fax:952-977-1802
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:952-993-6200
Practice Address - Fax:952-977-1802
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304457101YA0400X
MN02071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)