MEDICARE: AUTUMN GRAY

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	101YM0800X	Mental Health Counselor		WA

General Provider Information

NPI Number	:	1568323707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN GRAY

Provider Business Mailing Address
First Line	:	PO BOX 17481
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98127-1181
Country	:	US
Telephone Number	:	206-551-6270
Fax Number	:

Provider Business Practice Location Address
First Line	:	1417 NW 54TH ST STE 308
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-3573
Country	:	US
Telephone Number	:	206-551-6270
Fax Number	:

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

Provider Enumeration Date	:	11/18/2025
Last Update Date	:	11/18/2025

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Directions to “ AUTUMN GRAY ” Practice Location

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