Provider Demographics
NPI:1215659222
Name:HENDRICKS, AUTUMN LANAE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:LANAE
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 GRAND CASTLE BLVD SW APT E311
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1695
Mailing Address - Country:US
Mailing Address - Phone:313-970-8378
Mailing Address - Fax:
Practice Address - Street 1:2335 BURTON ST SE STE 210
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4669
Practice Address - Country:US
Practice Address - Phone:616-236-3600
Practice Address - Fax:616-369-1449
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical