Provider Demographics
NPI:1245666163
Name:TIMOTHY, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:TIMOTHY
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 1:2802 RETSOF AVENUE
Mailing Address - Street 2:
Mailing Address - City:RETSOF
Mailing Address - State:NY
Mailing Address - Zip Code:14539
Mailing Address - Country:US
Mailing Address - Phone:585-322-3864
Mailing Address - Fax:
Practice Address - Street 1:5871 GROVELAND STATION RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:NY
Practice Address - Zip Code:14510-9767
Practice Address - Country:US
Practice Address - Phone:585-658-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist