Healthcare Provider Details

I. General information

NPI: 1386449114
Provider Name (Legal Business Name): AUTUMN ROSE CIPRIANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 MAIN ST # A
FARMINGTON CT
06032-2985
US

IV. Provider business mailing address

1198 WOODTICK RD
WOLCOTT CT
06716-2125
US

V. Phone/Fax

Practice location:
  • Phone: 860-674-1824
  • Fax:
Mailing address:
  • Phone: 203-805-9544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number18.007997
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: