Healthcare Provider Details

I. General information

NPI: 1689165268
Provider Name (Legal Business Name): AUTUMN SIERRA HOLLOWAY CT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2018
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 BELMONT AVE
YOUNGSTOWN OH
44502-1039
US

IV. Provider business mailing address

711 BELMONT AVE
YOUNGSTOWN OH
44502-1039
US

V. Phone/Fax

Practice location:
  • Phone: 330-793-2487
  • Fax: 330-743-5748
Mailing address:
  • Phone: 330-793-2487
  • Fax: 330-743-5748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2002723-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: