Provider Demographics
NPI:1689209371
Name:AUTUMN LEAF THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:AUTUMN LEAF THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARILYN
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MSCP
Authorized Official - Phone:503-856-6430
Mailing Address - Street 1:3857 WOLVERINE ST NE STE 6
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-4274
Mailing Address - Country:US
Mailing Address - Phone:503-856-6430
Mailing Address - Fax:503-877-1920
Practice Address - Street 1:3857 WOLVERINE ST NE STE 6
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-4274
Practice Address - Country:US
Practice Address - Phone:503-856-6430
Practice Address - Fax:503-877-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty