Provider Demographics
NPI:1972176766
Name:SIMMONS, AUTUMN MORAN
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MORAN
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:2318 NE MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3715
Practice Address - Country:US
Practice Address - Phone:503-335-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-QMHA-R-2421101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health