Provider Demographics
NPI:1336682517
Name:MATTHEWS, AUTUMN
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:MATTHEWS
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 1:16424 DELWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:CA
Mailing Address - Zip Code:95315-9531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0510
Practice Address - Country:US
Practice Address - Phone:209-523-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI 95821101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional