Provider Demographics
NPI:1265184832
Name:GOSS, AUTUMN ROSE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:GOSS
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 1:4000 W METROPOLITAN DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3504
Mailing Address - Country:US
Mailing Address - Phone:855-625-4657
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3504
Practice Address - Country:US
Practice Address - Phone:855-625-4657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142261106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist