Provider Demographics
NPI:1770099749
Name:MCDONALD CARNEY, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MCDONALD CARNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 WILSON RUN RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON JCT
Mailing Address - State:KY
Mailing Address - Zip Code:40150-8567
Mailing Address - Country:US
Mailing Address - Phone:502-439-1787
Mailing Address - Fax:
Practice Address - Street 1:511 WILSON RUN RD
Practice Address - Street 2:
Practice Address - City:LEBANON JCT
Practice Address - State:KY
Practice Address - Zip Code:40150-8567
Practice Address - Country:US
Practice Address - Phone:502-439-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0583101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY101Y00000XMedicaid