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General NPI Number Information
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NPI Number | 1871029140
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Entity Type | Individual
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Provider Name | AUTUMN IRVINE SUDP, CAAR
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Gender | Female
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Dates
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Enumeration Date | 05/05/2017
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Last Update Date | 02/28/2023
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Provider Practice Location Address
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Address Line | 404 W MAIN ST
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City | KELSO
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State | WA
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Zip | 98626-1118
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Country | US
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Telephone | 360-423-2806
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Fax | 360-423-5128
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Provider Business Mailing Address
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Address Line | 913 OLSON RD APT A
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City | LONGVIEW
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State | WA
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Zip | 98632-5467
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Country | US
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Telephone | 360-270-1158
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CP 60188084
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | CG61313331
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License Number State | WA
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