Provider Demographics
NPI:1437924917
Name:WALLACE, AUTUMN (MA)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2299 WOODBURY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7854
Mailing Address - Country:US
Mailing Address - Phone:603-244-3187
Mailing Address - Fax:
Practice Address - Street 1:2299 WOODBURY AVE STE 1
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:NH
Practice Address - Zip Code:03801-7854
Practice Address - Country:US
Practice Address - Phone:603-244-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3078870Medicaid