Provider Demographics
NPI:1386001055
Name:STREETMAN, AUTUMN
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:
Last Name:STREETMAN
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 1:6 MATHIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165
Mailing Address - Country:US
Mailing Address - Phone:706-291-7201
Mailing Address - Fax:706-291-7198
Practice Address - Street 1:6 MATHIS DRIVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165
Practice Address - Country:US
Practice Address - Phone:706-291-7201
Practice Address - Fax:706-291-7198
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)