Basic Information
| Provider Information | |||||||||
| NPI: | 1912911090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1965 S FREMONT AVE | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178208180 | ||||||||
| FaxNumber: | 4178208183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 0102201521 | VA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 2010017178 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1912911090 | 05 | MO | MEDICAID | P00852000 | 01 | MO | RAILROAD MEDICARE # | OTHER | 183130003 | 05 | AR | MEDICAID |