Provider Demographics
NPI:1962646836
Name:AUTUMN HOUSE
Entity Type:Organization
Organization Name:AUTUMN HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:BS, QP
Authorized Official - Phone:336-273-2640
Mailing Address - Street 1:1000 REVOLUTION MILL DR
Mailing Address - Street 2:STUDIO #2
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5082
Mailing Address - Country:US
Mailing Address - Phone:336-273-2640
Mailing Address - Fax:336-273-6522
Practice Address - Street 1:3902 DERBYSHIRE DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2216
Practice Address - Country:US
Practice Address - Phone:336-288-7360
Practice Address - Fax:336-273-6522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTA PROFESSIONAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-874320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities