Provider Demographics
NPI:1114410073
Name:WESEBAUM, KARA BETH (LCSW)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:BETH
Last Name:WESEBAUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KARA
Other - Middle Name:BETH
Other - Last Name:VERGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 771
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-0771
Mailing Address - Country:US
Mailing Address - Phone:907-650-0222
Mailing Address - Fax:907-772-3710
Practice Address - Street 1:401 HAUGEN DRIVE
Practice Address - Street 2:#103
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-0771
Practice Address - Country:US
Practice Address - Phone:907-650-0222
Practice Address - Fax:907-772-3710
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
AK1734661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid