Provider Demographics
NPI:1730290743
Name:KARRAKER, AUDRIE L (LCSW)
Entity Type:Individual
Prefix:
First Name:AUDRIE
Middle Name:L
Last Name:KARRAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-2409
Mailing Address - Country:US
Mailing Address - Phone:203-333-6864
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:790 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06607-1705
Practice Address - Country:US
Practice Address - Phone:203-332-4567
Practice Address - Fax:203-332-4568
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0061911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006191OtherLICENSE