Provider Demographics
NPI:1922741990
Name:IMMINGAN, AUTUMN (PSYD)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:IMMINGAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:
Other - Last Name:VAN METER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:3000 C ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-3975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 C ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3975
Practice Address - Country:US
Practice Address - Phone:907-729-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist