Provider Demographics
NPI:1073178430
Name:ELLIOTT, AUTUMN
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 OCEAN AVE STE 19
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:527 OCEAN AVE STE 19
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4972
Practice Address - Country:US
Practice Address - Phone:207-573-7424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician