Provider Demographics
NPI:1194355693
Name:BAEHR, AUDREY (LADC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BAEHR
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PRIMROSE DR
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5040
Mailing Address - Country:US
Mailing Address - Phone:203-767-4594
Mailing Address - Fax:
Practice Address - Street 1:121 WAKELEE AVENUE
Practice Address - Street 2:ACS
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1198
Practice Address - Country:US
Practice Address - Phone:203-503-3650
Practice Address - Fax:203-503-3659
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT994101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid