Healthcare Provider Details

I. General information

NPI: 1346986759
Provider Name (Legal Business Name): CARRIE A LIU CSAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE RUDD CSAC

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 67TH ST
KENOSHA WI
53142-3836
US

IV. Provider business mailing address

4109 67TH ST
KENOSHA WI
53142-3836
US

V. Phone/Fax

Practice location:
  • Phone: 262-652-9830
  • Fax: 262-652-2931
Mailing address:
  • Phone: 262-652-9830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17027-132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: