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General NPI Number Information
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NPI Number | 1265105878
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Entity Type | Individual
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Provider Name | AUTUMN NICOLE WHITESIDE LLMSW
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Gender | Female
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Dates
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Enumeration Date | 07/29/2021
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Last Update Date | 07/29/2021
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Provider Practice Location Address
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Address Line | 882 OAKMAN BLVD STE D
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City | DETROIT
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State | MI
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Zip | 48238-4019
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Country | US
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Telephone | 313-961-7990
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Fax | 313-883-6261
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Provider Business Mailing Address
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Address Line | 27225 DEVONSHIRE ST
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City | SOUTHFIELD
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State | MI
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Zip | 48076-5639
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Country | US
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Telephone | 248-390-0956
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6851107419
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License Number State | MI
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