Provider Demographics
NPI:1508645011
Name:BROADWATER, AUTUMN ROSE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:BROADWATER
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 1:1920 20TH AVE NW APT B
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7928
Mailing Address - Country:US
Mailing Address - Phone:507-884-5491
Mailing Address - Fax:
Practice Address - Street 1:1920 20TH AVE NW APT B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-7928
Practice Address - Country:US
Practice Address - Phone:507-884-5491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician