Provider Demographics
NPI:1417447087
Name:MCCUIEN, AUTUMN GRACE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:GRACE
Last Name:MCCUIEN
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 1:1148 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8924
Mailing Address - Country:US
Mailing Address - Phone:949-300-0785
Mailing Address - Fax:
Practice Address - Street 1:1148 STANFORD AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8924
Practice Address - Country:US
Practice Address - Phone:949-300-0785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM250074288891103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst