=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477987071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUTUMN K MERRISS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2013
-----------------------------------------------------
Last Update Date | 06/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5966 SCOTTSVILLE RD STE 3
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104-7908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-791-8189
-----------------------------------------------------
Fax | 270-201-5890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 BRIDLEWOOD CT
-----------------------------------------------------
City | ALVATON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42122-8760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-799-1566
-----------------------------------------------------
Fax | 270-201-5980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3798
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------