Healthcare Provider Details

I. General information

NPI: 1609113240
Provider Name (Legal Business Name): AUTUMN WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 10/06/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2248 S 102ND ST. #155
WEST ALLIS WI
53227-2147
US

IV. Provider business mailing address

3900 W BROWN DEER RD SUITE 200
BROWN DEER WI
53209-1220
US

V. Phone/Fax

Practice location:
  • Phone: 414-541-5100
  • Fax: 844-515-9455
Mailing address:
  • Phone: 414-540-2170
  • Fax: 414-540-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1631-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5681-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: