Basic Information
| Provider Information | |||||||||
| NPI: | 1265006308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9240 BELTWAY 8 UNIT 110 | ||||||||
| Address2: | |||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557827822 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9240 BELTWAY 8 UNIT 110 | ||||||||
| Address2: | |||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557827822 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2021 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/28/2021 | ||||||||
| NPIReactivationDate: | 07/19/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | TX | N | 106S00000X | Y |
No ID Information.