Provider Demographics
NPI:1467690792
Name:KERN, AUTUMN E
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:E
Last Name:KERN
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 1:1437 SANTA CRUZ DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3865
Mailing Address - Country:US
Mailing Address - Phone:505-603-3923
Mailing Address - Fax:
Practice Address - Street 1:47 ALAMEDA RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3996
Practice Address - Country:US
Practice Address - Phone:505-454-9738
Practice Address - Fax:505-454-9285
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0142281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health