Healthcare Provider Details

I. General information

NPI: 1982206033
Provider Name (Legal Business Name): MICHAEL DEAN BARKER III BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BROADWAY AVE
PUEBLO CO
81004-2127
US

IV. Provider business mailing address

2285 FREMONT DR
CANON CITY CO
81212-2533
US

V. Phone/Fax

Practice location:
  • Phone: 719-425-7771
  • Fax:
Mailing address:
  • Phone: 719-431-2072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-22-13926
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-144415
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: