Provider Demographics
NPI:1962299941
Name:LILLARD, AUTUMN LOUISE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:LOUISE
Last Name:LILLARD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E 60TH ST APT 623
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-8305
Mailing Address - Country:US
Mailing Address - Phone:918-829-7563
Mailing Address - Fax:
Practice Address - Street 1:8922 S MEMORIAL DR STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4341
Practice Address - Country:US
Practice Address - Phone:918-615-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK195550225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist