Provider Demographics
NPI:1174900435
Name:AUTRY, OMEGA RUSHING (CDMS)
Entity type:Individual
Prefix:MRS
First Name:OMEGA
Middle Name:RUSHING
Last Name:AUTRY
Suffix:
Gender:F
Credentials:CDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 FARMHURST DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4923
Mailing Address - Country:US
Mailing Address - Phone:704-523-0021
Mailing Address - Fax:704-523-0809
Practice Address - Street 1:416 FARMHURST DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-4923
Practice Address - Country:US
Practice Address - Phone:704-523-0021
Practice Address - Fax:704-523-0809
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00046115101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor