Basic Information
| Provider Information | |||||||||
| NPI: | 1124766142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TALBOTT-CISNEROS | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | SERAPHINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2562 E 3210 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841092750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356401821 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH SALT LAKE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841153164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3856465000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2022 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 734604 | UT | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.