Provider Demographics
NPI:1124665047
Name:DOVE, AUTUMN ELIZABETH
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ELIZABETH
Last Name:DOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:ELIZABETH
Other - Last Name:HURLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 TIMBER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-7932
Mailing Address - Country:US
Mailing Address - Phone:501-326-8942
Mailing Address - Fax:
Practice Address - Street 1:211 TIMBER LAKE DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-7932
Practice Address - Country:US
Practice Address - Phone:501-326-8942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
1-21-50869103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician