Healthcare Provider Details

I. General information

NPI: 1841937869
Provider Name (Legal Business Name): AUTUMN HOLTSCHLAG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 N BROADWAY ST
CHICAGO IL
60613-4567
US

IV. Provider business mailing address

420 W MELROSE ST APT 203
CHICAGO IL
60657-3871
US

V. Phone/Fax

Practice location:
  • Phone: 773-496-4433
  • Fax:
Mailing address:
  • Phone: 989-252-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: