Healthcare Provider Details

I. General information

NPI: 1477199305
Provider Name (Legal Business Name): AUTUMN OLIVIA DOW LP, PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 651-628-9566
  • Fax: 651-628-0411
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1477199305
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: