Provider Demographics
NPI:1740482975
Name:AUTREY, DAVE
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:AUTREY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51950 PACIFIC WILLOW
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-9425
Mailing Address - Country:US
Mailing Address - Phone:541-617-7365
Mailing Address - Fax:541-312-6343
Practice Address - Street 1:461 NE GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-617-7365
Practice Address - Fax:541-312-6343
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR98-R-05101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)