Provider Demographics
NPI:1497293500
Name:BENNETT, AUTUMN ELIZABETH GRACE (CADC-R)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:ELIZABETH GRACE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CADC-R
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUTUMN WILSON
Mailing Address - Street 1:113 WILLAMETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7428
Mailing Address - Country:US
Mailing Address - Phone:541-941-1149
Mailing Address - Fax:
Practice Address - Street 1:300 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2756
Practice Address - Country:US
Practice Address - Phone:541-200-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information