MEDICARE: MS. AUTUMN MARIE BOCKHOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		MI

General Provider Information

NPI Number	:	1245192889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUTUMN MARIE BOCKHOL

Provider Business Mailing Address
First Line	:	2211 BETSIE RIVER RD
Second Line	:
City	:	INTERLOCHEN
State	:	MI
Zip	:	49643-9279
Country	:	US
Telephone Number	:	231-631-3387
Fax Number	:

Provider Business Practice Location Address
First Line	:	1363 DOUGLAS DR STE 104
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49696-8980
Country	:	US
Telephone Number	:	231-272-2472
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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