Healthcare Provider Details

I. General information

NPI: 1538095096
Provider Name (Legal Business Name): AUTUMN JUSTINA HERRERA TRAIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NW 27TH ST
CORVALLIS OR
97330-5223
US

IV. Provider business mailing address

PO BOX 579
CORVALLIS OR
97339-0579
US

V. Phone/Fax

Practice location:
  • Phone: 541-766-6767
  • Fax:
Mailing address:
  • Phone: 541-766-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number26-QMHA-R-8459
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: