Provider Demographics
NPI:1124994454
Name:KAHEA, AUTUMN NIKOLE HENNESSY (CPSS)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NIKOLE HENNESSY
Last Name:KAHEA
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 W 37 S
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-6177
Mailing Address - Country:US
Mailing Address - Phone:208-915-8448
Mailing Address - Fax:
Practice Address - Street 1:611 WILSON AVE STE 5
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5046
Practice Address - Country:US
Practice Address - Phone:208-915-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist