Provider Demographics
NPI:1629617667
Name:KUDRNA BEHRENT, KARRIE MAY (LPC-IT)
Entity Type:Individual
Prefix:MS
First Name:KARRIE
Middle Name:MAY
Last Name:KUDRNA BEHRENT
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N MAIN ST STE 612
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-4953
Mailing Address - Country:US
Mailing Address - Phone:920-385-6009
Mailing Address - Fax:866-327-3295
Practice Address - Street 1:PHOENIX BEHAVIORAL HEALTH SERVICES LLC
Practice Address - Street 2:3120 MEMORIAL DR.
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241
Practice Address - Country:US
Practice Address - Phone:920-657-1780
Practice Address - Fax:920-657-1784
Is Sole Proprietor?:No
Enumeration Date:2019-12-21
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101Y00000X, 101YA0400X, 101YM0800X, 106H00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist