Healthcare Provider Details

I. General information

NPI: 1245789429
Provider Name (Legal Business Name): AUTUMN ANDRUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2622 BRIARWOOD CT SE
KENTWOOD MI
49512-9084
US

IV. Provider business mailing address

7108 S KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 517-285-5260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: