Provider Demographics
NPI:1114592763
Name:RIDOUT, AUTUMN MARIE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:RIDOUT
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 1:522 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:FREWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14738-9742
Mailing Address - Country:US
Mailing Address - Phone:716-397-1772
Mailing Address - Fax:
Practice Address - Street 1:43 SINCLAIR DR
Practice Address - Street 2:
Practice Address - City:SINCLAIRVILLE
Practice Address - State:NY
Practice Address - Zip Code:14782-9637
Practice Address - Country:US
Practice Address - Phone:716-962-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010756-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant