Provider Demographics
NPI:1326820523
Name:HOTTLE, AUTUMN GRAY
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:GRAY
Last Name:HOTTLE
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 1:1761 BRUCETOWN RD
Mailing Address - Street 2:
Mailing Address - City:CLEAR BROOK
Mailing Address - State:VA
Mailing Address - Zip Code:22624-1114
Mailing Address - Country:US
Mailing Address - Phone:540-398-9445
Mailing Address - Fax:
Practice Address - Street 1:1120 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2418
Practice Address - Country:US
Practice Address - Phone:757-455-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606428225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant