Healthcare Provider Details

I. General information

NPI: 1205341286
Provider Name (Legal Business Name): AUTISM SPECIFIC CONSULTING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 12/15/2019
Certification Date: 12/15/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LACKAWANNA AVE STE 314
SCRANTON PA
18503-1953
US

IV. Provider business mailing address

201 LACKAWANNA AVE STE 314
SCRANTON PA
18503-1953
US

V. Phone/Fax

Practice location:
  • Phone: 570-354-2127
  • Fax: 570-507-9657
Mailing address:
  • Phone: 570-540-9428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH001844
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1034027290003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MR. KENNETH JOHN MATSKO JR.
Title or Position: PRESIDENT
Credential: BSL
Phone: 570-354-2127