Provider Demographics
NPI:1881964633
Name:BERRONES, AUDREA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AUDREA
Middle Name:
Last Name:BERRONES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1827
Mailing Address - Country:US
Mailing Address - Phone:859-288-2392
Mailing Address - Fax:859-721-3918
Practice Address - Street 1:218 MANDALAY RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:859-288-2425
Practice Address - Fax:859-721-3918
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62491041C0700X
KY39051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY270795565Medicaid