Basic Information
Provider Information | |||||||||
NPI: | 1912363250 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SDUNEK | ||||||||
FirstName: | AUTUMN | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, TLLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WARREN | ||||||||
OtherFirstName: | AUTUMN | ||||||||
OtherMiddleName: | N | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3410 OLD LANSING RD | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489174392 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5176572980 | ||||||||
FaxNumber: | 5179935982 | ||||||||
Practice Location | |||||||||
Address1: | 3410 OLD LANSING RD | ||||||||
Address2: |   | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489174392 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5176572980 | ||||||||
FaxNumber: | 5179935982 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/31/2015 | ||||||||
LastUpdateDate: | 12/31/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6301016346 | MI | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.