Provider Demographics
NPI:1013425644
Name:HASTEDT, AUTUMN ROSE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:HASTEDT
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 1:10906 COUNTY ROAD H
Mailing Address - Street 2:
Mailing Address - City:HAMLER
Mailing Address - State:OH
Mailing Address - Zip Code:43524-9766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-9194
Practice Address - Country:US
Practice Address - Phone:419-592-7966
Practice Address - Fax:419-599-0635
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023810225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist