Healthcare Provider Details

I. General information

NPI: 1750102760
Provider Name (Legal Business Name): AUTUMN WOODS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1027
LA FAYETTE GA
30728-1027
US

IV. Provider business mailing address

PO BOX 1027
LA FAYETTE GA
30728-1027
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5580
  • Fax: 888-861-8732
Mailing address:
  • Phone: 706-638-5580
  • Fax: 888-861-8732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMSW011551
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: