Provider Demographics
NPI:1174299713
Name:KUESPERT, AUTUMN (CTRS)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:KUESPERT
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:
Other - Last Name:WHITEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CTRS
Mailing Address - Street 1:1710 STOCKER PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-3254
Mailing Address - Country:US
Mailing Address - Phone:574-276-7854
Mailing Address - Fax:
Practice Address - Street 1:3220 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3028
Practice Address - Country:US
Practice Address - Phone:574-222-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker