Provider Demographics
NPI:1215443049
Name:VICKERY, FREDERICK MARCUS (LPPC, LADC)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:MARCUS
Last Name:VICKERY
Suffix:
Gender:M
Credentials:LPPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W LAKE ST STE 350
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2952
Mailing Address - Country:US
Mailing Address - Phone:651-895-7887
Mailing Address - Fax:
Practice Address - Street 1:621 W LAKE ST STE 350
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2952
Practice Address - Country:US
Practice Address - Phone:651-895-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1835101YP2500X
MN304457101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional