Provider Demographics
NPI:1427688514
Name:MULCAHY, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:MULCAHY
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 1:214 CHERYL LN APT 22
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-9785
Mailing Address - Country:US
Mailing Address - Phone:860-989-2552
Mailing Address - Fax:
Practice Address - Street 1:214 CHERYL LN APT 22
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:OR
Practice Address - Zip Code:97535-9785
Practice Address - Country:US
Practice Address - Phone:860-989-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X, 106S00000X
ORR7105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician