Provider Demographics
NPI:1306171889
Name:FREDRICKSON, RENEE (PHD, LP)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 BUCHER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8602
Mailing Address - Country:US
Mailing Address - Phone:651-646-8373
Mailing Address - Fax:
Practice Address - Street 1:1248 BUCHER AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55126-8602
Practice Address - Country:US
Practice Address - Phone:651-646-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2653103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling