Provider Demographics
NPI:1154980068
Name:PHENOW, AUTUMN MICHELLE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MICHELLE
Last Name:PHENOW
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 WHITE BEAR AVE N STE 403
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1327
Mailing Address - Country:US
Mailing Address - Phone:651-395-5775
Mailing Address - Fax:
Practice Address - Street 1:6341 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4946
Practice Address - Country:US
Practice Address - Phone:612-672-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN226511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical