Provider Demographics
NPI:1053452201
Name:IRICK, KAREN MARIE (LCSW, LAC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:IRICK
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1558
Mailing Address - Country:US
Mailing Address - Phone:719-544-3150
Mailing Address - Fax:816-781-1111
Practice Address - Street 1:1530 W 17TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-544-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040190981041C0700X
COACD.0000976101YA0400X
COCSW.099242781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
COACD.0000976OtherLAC
MO13279718Medicaid
MO2004019098OtherLCSW
COCSW.09924278OtherLCSW