Provider Demographics
NPI:1023510658
Name:BJORNSTAD, AUTUMN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:BJORNSTAD
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22447 CORTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1367
Mailing Address - Country:US
Mailing Address - Phone:586-354-0602
Mailing Address - Fax:
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-576-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000746235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist