Provider Demographics
NPI:1649930769
Name:SKATES, AUTUMN MARIE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:SKATES
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 1:203 N KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784
Mailing Address - Country:US
Mailing Address - Phone:407-982-0818
Mailing Address - Fax:
Practice Address - Street 1:15425 SOUTHERN MARTIN ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4898
Practice Address - Country:US
Practice Address - Phone:407-810-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty