Provider Demographics
NPI:1184102139
Name:SNELL, AUTUMN
Entity type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:
Last Name:SNELL
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 1:30902 CLUBHOUSE DR UNIT 1J
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2378
Mailing Address - Country:US
Mailing Address - Phone:949-295-4199
Mailing Address - Fax:
Practice Address - Street 1:7700 IRVINE CENTER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2923
Practice Address - Country:US
Practice Address - Phone:760-815-2396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health