Healthcare Provider Details

I. General information

NPI: 1104254432
Provider Name (Legal Business Name): AUTUMN OWODUNNI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 SLATER ST APT 416
MANCHESTER CT
06042-8922
US

IV. Provider business mailing address

110 MAPLE ST
SPRINGFIELD MA
01105-1864
US

V. Phone/Fax

Practice location:
  • Phone: 718-207-8900
  • Fax:
Mailing address:
  • Phone: 413-732-7419
  • Fax: 413-781-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6724
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: