Healthcare Provider Details

I. General information

NPI: 1467690792
Provider Name (Legal Business Name): AUTUMN E KERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 ALAMEDA RD
LAS VEGAS NM
87701-3996
US

IV. Provider business mailing address

1437 SANTA CRUZ DR
SANTA FE NM
87505-3865
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-9738
  • Fax: 505-454-9285
Mailing address:
  • Phone: 505-603-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0142281
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: