Provider Demographics
NPI:1629628409
Name:GUSDAL, AUTUMN L (BIS)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:L
Last Name:GUSDAL
Suffix:
Gender:F
Credentials:BIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7659
Mailing Address - Country:US
Mailing Address - Phone:208-704-0717
Mailing Address - Fax:
Practice Address - Street 1:210 E 14TH AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7659
Practice Address - Country:US
Practice Address - Phone:208-704-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician