Provider Demographics
NPI:1477230795
Name:HENDERSON, AUTUMN (M ED)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11632 W SANTA BARBARA DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6638
Mailing Address - Country:US
Mailing Address - Phone:208-340-5677
Mailing Address - Fax:
Practice Address - Street 1:11632 W SANTA BARBARA DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6638
Practice Address - Country:US
Practice Address - Phone:208-340-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist