Provider Demographics
NPI:1427789551
Name:COMPO, AUTUMN (LMT)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:COMPO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 E FLORENCE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-4153
Mailing Address - Country:US
Mailing Address - Phone:520-635-5585
Mailing Address - Fax:
Practice Address - Street 1:623 E FLORENCE BLVD STE A
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4153
Practice Address - Country:US
Practice Address - Phone:520-635-5585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT24021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist