Provider Demographics
NPI:1114542958
Name:BAHLKE, AUTUMN N (LMT)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:N
Last Name:BAHLKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1242
Mailing Address - Country:US
Mailing Address - Phone:616-249-8141
Mailing Address - Fax:
Practice Address - Street 1:3010 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1242
Practice Address - Country:US
Practice Address - Phone:616-249-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003583225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501003583OtherNA