Healthcare Provider Details

I. General information

NPI: 1528908688
Provider Name (Legal Business Name): AUTUMN ROSE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 BIG TEXAS VALLEY RD NW
ROME GA
30165-9753
US

IV. Provider business mailing address

6095 BIG TEXAS VALLEY RD NW
ROME GA
30165-9753
US

V. Phone/Fax

Practice location:
  • Phone: 619-342-5933
  • Fax:
Mailing address:
  • Phone: 619-342-5933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC010509
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: