MEDICARE: AUTUMN SKYE IRIZARRY RBT

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	106S00000X	Behavior Technician	RBT-15-09899

General Provider Information

NPI Number	:	1407361496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN SKYE IRIZARRY RBT

Provider Business Mailing Address
First Line	:	5446 N ACADEMY BLVD STE 105
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3668
Country	:	US
Telephone Number	:	719-246-8440
Fax Number	:

Provider Business Practice Location Address
First Line	:	5446 N ACADEMY BLVD STE 105
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-3668
Country	:	US
Telephone Number	:	719-246-8440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2017
Last Update Date	:	12/12/2017

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