Basic Information
| Provider Information | |||||||||
| NPI: | 1891923272 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSON | ||||||||
| FirstName: | GINGER | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | PO BOX 9859 | ||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014514893 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 3RD ST N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563034033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202535930 | ||||||||
| FaxNumber: | 3202584632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2761 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.