Provider Demographics
NPI:1598363608
Name:MATLOCK, REGAN MELISSA (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:REGAN
Middle Name:MELISSA
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:MISS
Other - First Name:REGAN
Other - Middle Name:MELISSA
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:7333 INTERNATIONAL PL
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8418
Mailing Address - Country:US
Mailing Address - Phone:941-907-3500
Mailing Address - Fax:941-527-0526
Practice Address - Street 1:7333 INTERNATIONAL PL
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240-8418
Practice Address - Country:US
Practice Address - Phone:941-907-3500
Practice Address - Fax:941-527-0526
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-55955103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst