Provider Demographics
NPI:1346986759
Name:LIU, CARRIE A (CSAC)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:LIU
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:RUDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSAC
Mailing Address - Street 1:4109 67TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3836
Mailing Address - Country:US
Mailing Address - Phone:262-652-9830
Mailing Address - Fax:
Practice Address - Street 1:4109 67TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3836
Practice Address - Country:US
Practice Address - Phone:262-652-9830
Practice Address - Fax:262-652-2931
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17027-132101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)