Provider Demographics
NPI:1376883983
Name:ROSS, AUTUMN DANIEL (LCMHC)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:DANIEL
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 PEARL ST APT 1734
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-3846
Mailing Address - Country:US
Mailing Address - Phone:864-341-7111
Mailing Address - Fax:
Practice Address - Street 1:4420 TRIUMPH DR SW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-2707
Practice Address - Country:US
Practice Address - Phone:864-341-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9685101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health