Healthcare Provider Details

I. General information

NPI: 1700219847
Provider Name (Legal Business Name): AUTUMN R. HENNING MSCCCSLPCOMIBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 PRADO WAY
GREENVILLE SC
29607-6512
US

IV. Provider business mailing address

345 PRADO WAY STE B
GREENVILLE SC
29607-6512
US

V. Phone/Fax

Practice location:
  • Phone: 864-383-8634
  • Fax: 864-383-8633
Mailing address:
  • Phone: 864-383-8634
  • Fax: 864-383-8633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5607
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: