Provider Demographics
NPI:1720655822
Name:SANDERS, AUTUMN EVE (NA-R)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:EVE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:NA-R
Other - Prefix:
Other - First Name:ASHOUN
Other - Middle Name:
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19204 N CREEK PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-8009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19204 N CREEK PKWY STE 110
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-8009
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician