Healthcare Provider Details

I. General information

NPI: 1306779483
Provider Name (Legal Business Name): AUTUMN LEAF LANCETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 ERIE BLVD W STE 300D
SYRACUSE NY
13204-2463
US

IV. Provider business mailing address

1810 W GENESEE ST
SYRACUSE NY
13204-1867
US

V. Phone/Fax

Practice location:
  • Phone: 315-677-7330
  • Fax:
Mailing address:
  • Phone: 315-264-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017933
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: