Provider Demographics
NPI:1811032121
Name:AUTRY, PUSHPA (MFT)
Entity Type:Individual
Prefix:
First Name:PUSHPA
Middle Name:
Last Name:AUTRY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4671
Mailing Address - Country:US
Mailing Address - Phone:916-688-4398
Mailing Address - Fax:916-688-6264
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:916-688-4398
Practice Address - Fax:916-688-6264
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT37063106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist