Provider Demographics
NPI:1245767904
Name:TRUETT, AUDREY GRACE (CSW)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:GRACE
Last Name:TRUETT
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-9594
Mailing Address - Country:US
Mailing Address - Phone:859-986-2323
Mailing Address - Fax:
Practice Address - Street 1:104 LEGACY DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-9594
Practice Address - Country:US
Practice Address - Phone:859-986-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252597104100000X
101YM0800X, 171M00000X
KY2551861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator