Healthcare Provider Details

I. General information

NPI: 1699370809
Provider Name (Legal Business Name): AUTUMN VICTORIA GRACE HAMPTON MASTERS PSYCHOLOGY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 CORAL TRACE BLVD
EDGEWATER FL
32132-6942
US

IV. Provider business mailing address

648 CORAL TRACE BLVD
EDGEWATER FL
32132-6942
US

V. Phone/Fax

Practice location:
  • Phone: 606-259-6072
  • Fax:
Mailing address:
  • Phone: 606-259-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: