Provider Demographics
NPI:1699339978
Name:GONZALEZ, AUTUMN ASHLEY (LCPC, LMHP, CAADC)
Entity type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:ASHLEY
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LCPC, LMHP, CAADC
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:ASHLEY
Other - Last Name:DEKOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1701 RIVER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-1384
Mailing Address - Country:US
Mailing Address - Phone:309-762-5433
Mailing Address - Fax:309-762-4481
Practice Address - Street 1:4101 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-9951
Practice Address - Country:US
Practice Address - Phone:309-762-5433
Practice Address - Fax:309-762-4481
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL36433101YA0400X
IA108785101YP2500X
IL180.013574101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)