MEDICARE: AUTUMN LARSON HOOVER CMHC, MRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	314561-6009	UT
2	101YM0800X	Mental Health Counselor	314561-6004	UT

General Provider Information

NPI Number	:	1407432545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN LARSON HOOVER CMHC, MRC

Provider Business Mailing Address
First Line	:	1269 E 1900 N
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-2009
Country	:	US
Telephone Number	:	435-720-6632
Fax Number	:

Provider Business Practice Location Address
First Line	:	1269 E 1900 N
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-2009
Country	:	US
Telephone Number	:	435-720-6632
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2021
Last Update Date	:	12/04/2024

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