Provider Demographics
NPI:1396405585
Name:CLOUD-INGRAM, AUTUMN
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:CLOUD-INGRAM
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 1:932 LITCHFIELD TPKE
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-3019
Mailing Address - Country:US
Mailing Address - Phone:203-390-0070
Mailing Address - Fax:
Practice Address - Street 1:932 LITCHFIELD TPKE
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:CT
Practice Address - Zip Code:06524-3019
Practice Address - Country:US
Practice Address - Phone:203-390-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT119551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical