Provider Demographics
NPI:1326792912
Name:CHASE, AUTUMN (LPCA)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:CHASE
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 PARK CIR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4832
Mailing Address - Country:US
Mailing Address - Phone:860-906-2147
Mailing Address - Fax:
Practice Address - Street 1:475 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1700
Practice Address - Country:US
Practice Address - Phone:203-368-5632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health