Healthcare Provider Details

I. General information

NPI: 1518823848
Provider Name (Legal Business Name): AUTUMN STAR STREAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 892
FERRON UT
84523-0892
US

IV. Provider business mailing address

PO BOX 892
FERRON UT
84523-0892
US

V. Phone/Fax

Practice location:
  • Phone: 435-381-4357
  • Fax:
Mailing address:
  • Phone: 435-381-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: