Healthcare Provider Details

I. General information

NPI: 1053452201
Provider Name (Legal Business Name): KAREN MARIE IRICK LCSW, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 W 17TH ST
PUEBLO CO
81003
US

IV. Provider business mailing address

1530 W 17TH ST
PUEBLO CO
81003-1558
US

V. Phone/Fax

Practice location:
  • Phone: 719-544-3150
  • Fax:
Mailing address:
  • Phone: 719-544-3150
  • Fax: 816-781-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0000976
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2004019098
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09924278
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: