Provider Demographics
NPI:1174085393
Name:AVASAKDI, MATTHEW N (BCBA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:N
Last Name:AVASAKDI
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 BROWN STONE VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-4492
Mailing Address - Country:US
Mailing Address - Phone:941-275-4422
Mailing Address - Fax:
Practice Address - Street 1:1930 FREQUENT FLYER PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1500
Practice Address - Country:US
Practice Address - Phone:941-275-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-50060106S00000X
1-20-43166103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102463800Medicaid