Provider Demographics
NPI:1871029140
Name:IRVINE, AUTUMN (SUDP, CAAR)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:IRVINE
Suffix:
Gender:F
Credentials:SUDP, CAAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 OLSON RD APT A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-5467
Mailing Address - Country:US
Mailing Address - Phone:360-270-1158
Mailing Address - Fax:
Practice Address - Street 1:404 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1118
Practice Address - Country:US
Practice Address - Phone:360-423-2806
Practice Address - Fax:360-423-5128
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 60188084101YA0400X
WACG61313331101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)