Provider Demographics
NPI:1770252124
Name:MATSUTANI, AUTUMN LEE (MA, CRC, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:LEE
Last Name:MATSUTANI
Suffix:
Gender:F
Credentials:MA, CRC, LPC, NCC
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:LEE
Other - Last Name:DERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CRC, LPCC, NCC
Mailing Address - Street 1:1300 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-9584
Mailing Address - Country:US
Mailing Address - Phone:970-347-2120
Mailing Address - Fax:
Practice Address - Street 1:1306 11TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-3835
Practice Address - Country:US
Practice Address - Phone:970-347-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020371101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional