Provider Demographics
NPI:1457349870
Name:AUTUMN, CONNIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
Last Name:AUTUMN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 IRON HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-5308
Mailing Address - Country:US
Mailing Address - Phone:215-997-8815
Mailing Address - Fax:215-822-1471
Practice Address - Street 1:39 IRON HILL RD
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:PA
Practice Address - Zip Code:18901-5308
Practice Address - Country:US
Practice Address - Phone:215-997-8815
Practice Address - Fax:215-822-1471
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0137541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7056198Medicaid
01663404OtherPERSONAL CHOICE
118314OtherMENTAL HEALTH NETWORK
475996OtherVALUE OPTIONS
8033730OtherTRICARE
PA633755Medicare ID - Type Unspecified
8033730OtherTRICARE