Provider Demographics
NPI:1093260770
Name:WACKETT, KAREN ALANE (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:ALANE
Last Name:WACKETT
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:LASTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:1813 SWEETBAY DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-1663
Practice Address - Country:US
Practice Address - Phone:410-219-5483
Practice Address - Fax:410-219-5486
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD221701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
MD119591300Medicaid
MDS118Medicare PIN