Healthcare Provider Details

I. General information

NPI: 1275985236
Provider Name (Legal Business Name): AUTUMN BAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W RAMSEY ST
DAWSON SPRINGS KY
42408-1739
US

IV. Provider business mailing address

100 W RAMSEY ST
DAWSON SPRINGS KY
42408-1739
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-5092
  • Fax:
Mailing address:
  • Phone: 616-975-5092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberBOTOCT00220887
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: