Provider Demographics
NPI:1477987071
Name:MERRISS, AUTUMN K (LCSW)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:K
Last Name:MERRISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:K
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:160 BRIDLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-8760
Mailing Address - Country:US
Mailing Address - Phone:270-799-1566
Mailing Address - Fax:270-201-5980
Practice Address - Street 1:5966 SCOTTSVILLE RD STE 3
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-7908
Practice Address - Country:US
Practice Address - Phone:270-791-8189
Practice Address - Fax:270-201-5890
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100297730Medicaid