Provider Demographics
NPI:1407138746
Name:WATERS, AUTUMN LYN (LMT)
Entity Type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:LYN
Last Name:WATERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4729
Mailing Address - Country:US
Mailing Address - Phone:503-371-4968
Mailing Address - Fax:
Practice Address - Street 1:417 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4729
Practice Address - Country:US
Practice Address - Phone:503-371-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT 17282175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath