MEDICARE: AUTUMN FAWN HOWARD I

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	225200000X	Physical Therapy Assistant	5502001683	MI

General Provider Information

NPI Number	:	1811411010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN FAWN HOWARD I

Provider Business Mailing Address
First Line	:	1800 E JORDAN RD LOT 1
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-9746
Country	:	US
Telephone Number	:	989-560-4661
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 E JORDAN RD LOT 1
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-9746
Country	:	US
Telephone Number	:	989-560-4661
Fax Number	:

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

Provider Enumeration Date	:	07/28/2017
Last Update Date	:	07/21/2022

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