Provider Demographics
NPI:1134305113
Name:BRAEUTIGAM, KAREN J (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:J
Last Name:BRAEUTIGAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 ROUTE 73
Mailing Address - Street 2:PO BOX 18
Mailing Address - City:ORWELL
Mailing Address - State:VT
Mailing Address - Zip Code:05760-9782
Mailing Address - Country:US
Mailing Address - Phone:802-775-2176
Mailing Address - Fax:
Practice Address - Street 1:78 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4591
Practice Address - Country:US
Practice Address - Phone:802-775-8224
Practice Address - Fax:802-747-7699
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-0001220101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1014567Medicaid