Provider Demographics
NPI:1114573490
Name:CONKLIN, AUTUMN A (CDCA)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:A
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1628
Mailing Address - Country:US
Mailing Address - Phone:740-693-4113
Mailing Address - Fax:
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-6220
Practice Address - Country:US
Practice Address - Phone:740-899-4005
Practice Address - Fax:740-899-4023
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.174316101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)