Provider Demographics
NPI:1053433599
Name:FALK-O'DENIUS, AUTUMN VIVIENNE (LAC LMP)
Entity type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:VIVIENNE
Last Name:FALK-O'DENIUS
Suffix:
Gender:F
Credentials:LAC LMP
Other - Prefix:MRS
Other - First Name:AUTUMN
Other - Middle Name:
Other - Last Name:ODENIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 181
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292
Mailing Address - Country:US
Mailing Address - Phone:425-530-0594
Mailing Address - Fax:360-659-3918
Practice Address - Street 1:9123 271ST NW
Practice Address - Street 2:S
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292
Practice Address - Country:US
Practice Address - Phone:425-530-0594
Practice Address - Fax:360-659-3918
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
WAAC61413207171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA364802001OtherPREMERA
WA108835OtherL & I