Provider Demographics
NPI: | 1245767904 |
---|---|
Name: | TRUETT, AUDREY GRACE (CSW) |
Entity Type: | Individual |
Prefix: | |
First Name: | AUDREY |
Middle Name: | GRACE |
Last Name: | TRUETT |
Suffix: | |
Gender: | F |
Credentials: | CSW |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 104 LEGACY DR |
Mailing Address - Street 2: | |
Mailing Address - City: | BEREA |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40403-9594 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 859-986-2323 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 104 LEGACY DR |
Practice Address - Street 2: | |
Practice Address - City: | BEREA |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40403-9594 |
Practice Address - Country: | US |
Practice Address - Phone: | 859-986-2323 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2017-05-12 |
Last Update Date: | 2020-10-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 252597 | 104100000X |
101YM0800X, 171M00000X | ||
KY | 255186 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator |