Provider Demographics
NPI:1750812889
Name:AUTUMN TREE THERAPY
Entity type:Organization
Organization Name:AUTUMN TREE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN-FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW CMC
Authorized Official - Phone:303-875-2364
Mailing Address - Street 1:2935 BASELINE RD
Mailing Address - Street 2:STE. 302
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2366
Mailing Address - Country:US
Mailing Address - Phone:303-875-2364
Mailing Address - Fax:
Practice Address - Street 1:2935 BASELINE RD
Practice Address - Street 2:STE. 302
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2366
Practice Address - Country:US
Practice Address - Phone:303-875-2364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54105081Medicaid