Provider Demographics
NPI:1740154111
Name:CAMPBELL, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:CAMPBELL
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 1:4793 WAKEFIELD AVE NE
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8958
Mailing Address - Country:US
Mailing Address - Phone:810-449-9715
Mailing Address - Fax:
Practice Address - Street 1:4500 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3665
Practice Address - Country:US
Practice Address - Phone:616-277-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI451024603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health