MEDICARE: MOUNTAIN ABA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1790625838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN ABA LLC

Provider Business Mailing Address
First Line	:	2300 SUNSTONE DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-8024
Country	:	US
Telephone Number	:	505-333-8718
Fax Number	:

Provider Business Practice Location Address
First Line	:	2300 SUNSTONE DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-8024
Country	:	US
Telephone Number	:	505-333-8718
Fax Number	:

Authorized Official
Title or Position	:	BCBA
Name	:	ANDRE AZEVEDO
Credential	:	M.ED.
Telephone Number	:	817-526-8290

Provider Enumeration Date	:	03/30/2026
Last Update Date	:	03/30/2026

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Directions to “MOUNTAIN ABA LLC ” Practice Location

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