Provider Demographics
NPI:1053990382
Name:WRIGHT, AUTUMN NICOLE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICOLE
Last Name:WRIGHT
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 1:2221 MOUNT CARMEL AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-4735
Mailing Address - Country:US
Mailing Address - Phone:215-303-8336
Mailing Address - Fax:
Practice Address - Street 1:2566 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1743
Practice Address - Country:US
Practice Address - Phone:215-303-8336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225600000X
PAPC018223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist