Provider Demographics
NPI:1942856265
Name:QUIROZ, AUTUMN L
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:L
Last Name:QUIROZ
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 1:211 SE 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1539
Mailing Address - Country:US
Mailing Address - Phone:971-202-6431
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-12-02
Deactivation Date:2019-09-23
Deactivation Code:
Reactivation Date:2019-09-30
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician