Gary J Fredericksen, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

LW00004165 Issued in WA

Practice address

4422 6TH Ave SE
Lacey, WA 98503-1020

Phone

(360) 704-7170

Fax

(360) 412-4982

NPI assigned

Nov 20, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163980800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1184889600000",
    "number": "1700950557",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4422 6TH AVE SE",
            "city": "LACEY",
            "state": "WA",
            "postal_code": "985031020",
            "telephone_number": "360-704-7170",
            "fax_number": "360-412-4982"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4422 6TH AVE SE",
            "city": "LACEY",
            "state": "WA",
            "postal_code": "985031020",
            "telephone_number": "360-704-7170",
            "fax_number": "360-412-4982"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FREDERICKSEN",
        "first_name": "GARY",
        "middle_name": "J",
        "name_prefix": "Mr.",
        "credential": "LICSW",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-11-20",
        "last_updated": "2007-07-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "WA",
            "license": "LW00004165",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "WA",
            "license": "LW00004165",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Social Worker in Lacey, WA
• Providers in Lacey, WA by specialty
• Clinical Social Worker in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 20, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.