=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396493367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTUMN SUN MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2022
-----------------------------------------------------
Last Update Date | 07/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4328 N COUNTY ROAD 19
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80524-9748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-645-6228
-----------------------------------------------------
Fax | 970-233-9830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 719
-----------------------------------------------------
City | LAPORTE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80535-0719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-645-6228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | LAURA TURK
-----------------------------------------------------
Credential | PMHNP, FNP
-----------------------------------------------------
Telephone | 970-645-6228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------