Provider Demographics
NPI:1265105878
Name:WHITESIDE, AUTUMN NICOLE (LLMSW)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICOLE
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27225 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5639
Mailing Address - Country:US
Mailing Address - Phone:248-390-0956
Mailing Address - Fax:
Practice Address - Street 1:882 OAKMAN BLVD STE D
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4019
Practice Address - Country:US
Practice Address - Phone:313-961-7990
Practice Address - Fax:313-883-6261
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851107419104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker