Provider Demographics
NPI:1336433986
Name:HEINSELMAN, AUTUMN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:HEINSELMAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7025 REED CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7950
Mailing Address - Country:US
Mailing Address - Phone:904-662-0563
Mailing Address - Fax:
Practice Address - Street 1:5437 EISENHAUER RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-3757
Practice Address - Country:US
Practice Address - Phone:210-646-9576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106131235Z00000X, 314000000X
SC4547235Z00000X
NC9097235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility