Provider Demographics
NPI:1770648768
Name:GUDGER, KAREN (LCSW)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:GUDGER
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 1:317 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3745
Mailing Address - Country:US
Mailing Address - Phone:770-516-7138
Mailing Address - Fax:770-516-3018
Practice Address - Street 1:317 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3745
Practice Address - Country:US
Practice Address - Phone:770-516-7138
Practice Address - Fax:770-516-3018
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58202790430188A003OtherTRICARE
GA58202790430188A003OtherTRICARE
GAR13044Medicare UPIN