Basic Information
| Provider Information | |||||||||
| NPI: | 1912216326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHALEY | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | MELODY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS, MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | AUTUMN | ||||||||
| OtherMiddleName: | MELODY WHALEY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1750 NEBRASKA AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414745579 | ||||||||
| FaxNumber: | 5414745842 | ||||||||
| Practice Location | |||||||||
| Address1: | 1750 NEBRASKA AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414745579 | ||||||||
| FaxNumber: | 5414745842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2010 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C3891 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.