Healthcare Provider Details

I. General information

NPI: 1780446542
Provider Name (Legal Business Name): AUTUMN HOPE BONGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N PATRICK BLVD STE 250
BROOKFIELD WI
53045-5883
US

IV. Provider business mailing address

200 N PATRICK BLVD STE 250
BROOKFIELD WI
53045-5883
US

V. Phone/Fax

Practice location:
  • Phone: 920-878-2003
  • Fax:
Mailing address:
  • Phone: 920-878-2003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: