MEDICARE: AUTUMN RE

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	104100000X	Social Worker	LMSW-22984	AZ

General Provider Information

NPI Number	:	1326971094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN RE

Provider Business Mailing Address
First Line	:	3347 N WINDSONG DR FL 2
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-2283
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3347 N WINDSONG DR FL 2
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-2283
Country	:	US
Telephone Number	:	928-445-5211
Fax Number	:

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

Provider Enumeration Date	:	06/04/2026
Last Update Date	:	06/04/2026

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Directions to “ AUTUMN RE ” Practice Location

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