Provider Demographics
NPI:1073882536
Name:WEATHERFORD, MATTHEW WAYNE (BCBA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:WEATHERFORD
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 1:5001 PAR DR APT 3613
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-6786
Mailing Address - Country:US
Mailing Address - Phone:940-368-4597
Mailing Address - Fax:
Practice Address - Street 1:2815 EXCHANGE BLVD
Practice Address - Street 2:100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7514
Practice Address - Country:US
Practice Address - Phone:817-479-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1119293103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst